Healthcare Provider Details

I. General information

NPI: 1366091928
Provider Name (Legal Business Name): STACY KUPHAL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 EDGELL RD STE 32
FRAMINGHAM MA
01701-4868
US

IV. Provider business mailing address

5 EDGELL RD STE 32
FRAMINGHAM MA
01701-4868
US

V. Phone/Fax

Practice location:
  • Phone: 857-273-2123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number224066
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: