Healthcare Provider Details

I. General information

NPI: 1336757566
Provider Name (Legal Business Name): KAYLA CUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date: 05/22/2024
Reactivation Date: 10/21/2024

III. Provider practice location address

2074 CUPOLA DR UNIT 300
LOVELAND CO
80538
US

IV. Provider business mailing address

125 CRESTRIDGE ST STE 1
FORT COLLINS CO
80525
US

V. Phone/Fax

Practice location:
  • Phone: 970-227-4596
  • Fax:
Mailing address:
  • Phone: 970-942-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0022109
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: