Healthcare Provider Details

I. General information

NPI: 1366740896
Provider Name (Legal Business Name): WILLIAM RILEY HUPP JR. LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 INDIAN WOOD CIR STE 100
MAUMEE OH
43537-4029
US

IV. Provider business mailing address

PO BOX 823
PERRYSBURG OH
43552-0823
US

V. Phone/Fax

Practice location:
  • Phone: 419-491-0420
  • Fax: 567-698-7875
Mailing address:
  • Phone: 419-491-0420
  • Fax: 567-698-7875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number867
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: