Healthcare Provider Details

I. General information

NPI: 1710532700
Provider Name (Legal Business Name): GRACE ELLEN KUPISZEWSKI DPT,PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 RED BUG LAKE RD
OVIEDO FL
32765-7154
US

IV. Provider business mailing address

1200 LEXINGTON GREEN LN
SANFORD FL
32771-1013
US

V. Phone/Fax

Practice location:
  • Phone: 407-971-2774
  • Fax: 407-971-2776
Mailing address:
  • Phone: 407-322-3442
  • Fax: 407-322-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT34863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: