Healthcare Provider Details

I. General information

NPI: 1558067066
Provider Name (Legal Business Name): EDY KUPIETZKY MSW, PHD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 WINNETKA AVE
WINNETKA IL
60093-4206
US

IV. Provider business mailing address

9110 KARLOV AVE
SKOKIE IL
60076-1718
US

V. Phone/Fax

Practice location:
  • Phone: 773-425-1905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: