Healthcare Provider Details

I. General information

NPI: 1174993273
Provider Name (Legal Business Name): KRISTINE KUPCHA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 2ND AVE N STE 203C
NORTH MYRTLE BEACH SC
29582-3288
US

IV. Provider business mailing address

1016 2ND AVE N STE 203C
NORTH MYRTLE BEACH SC
29582-3288
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-6188
  • Fax:
Mailing address:
  • Phone:
  • Fax: 802-888-6393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: