Healthcare Provider Details

I. General information

NPI: 1326265851
Provider Name (Legal Business Name): MICHAEL CUPP TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 CAPITAL AVE SW SUITE 1
BATTLE CREEK MI
49015-7375
US

IV. Provider business mailing address

3630 CAPITAL AVE SW SUITE 1
BATTLE CREEK MI
49015-7375
US

V. Phone/Fax

Practice location:
  • Phone: 269-979-8333
  • Fax: 269-979-7766
Mailing address:
  • Phone: 269-979-8333
  • Fax: 269-979-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301013001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: