Healthcare Provider Details

I. General information

NPI: 1871781229
Provider Name (Legal Business Name): MS. KATHY MARIE RUPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MODESTO AVE
MODESTO CA
95354-0414
US

IV. Provider business mailing address

1824 SKYLANE WAY
MODESTO CA
95350-2654
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-4597
  • Fax:
Mailing address:
  • Phone: 209-522-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: