Healthcare Provider Details

I. General information

NPI: 1205211067
Provider Name (Legal Business Name): JOTHI MALAR KUPPUSAMY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 FORTVIEW ROAD SUITE 105
AUSTIN TX
78704-7657
US

IV. Provider business mailing address

1825 FORTVIEW RD SUITE 105
AUSTIN TX
78704-7657
US

V. Phone/Fax

Practice location:
  • Phone: 512-351-7837
  • Fax: 512-900-1275
Mailing address:
  • Phone: 512-351-7837
  • Fax: 512-900-1275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-15-19246
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: