Healthcare Provider Details

I. General information

NPI: 1871902007
Provider Name (Legal Business Name): KAYLA CHUPCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 MOHAWK BLVD
TULSA OK
74110
US

IV. Provider business mailing address

P.O. BOX 580700
TULSA OK
74158
US

V. Phone/Fax

Practice location:
  • Phone: 918-430-0975
  • Fax: 918-430-0995
Mailing address:
  • Phone: 918-430-0945
  • Fax: 918-430-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: