Healthcare Provider Details

I. General information

NPI: 1720385958
Provider Name (Legal Business Name): HEATHER B KUPCSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6222 MAIN ST
DOWNERS GROVE IL
60516-1908
US

IV. Provider business mailing address

2210 DEAN ST STE L
SAINT CHARLES IL
60175-1059
US

V. Phone/Fax

Practice location:
  • Phone: 630-663-9002
  • Fax: 630-663-9470
Mailing address:
  • Phone: 888-510-0766
  • Fax: 763-268-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147.001360
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: