Healthcare Provider Details

I. General information

NPI: 1588107403
Provider Name (Legal Business Name): MATTHEW CUPPETT LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2016
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 OLD COLLINSVILLE RD
SWANSEA IL
62226-2025
US

IV. Provider business mailing address

4950 OLD COLLINSVILLE RD
SWANSEA IL
62226-2025
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-4164
  • Fax: 618-382-3239
Mailing address:
  • Phone: 618-382-4164
  • Fax: 618-382-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.012532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: