Healthcare Provider Details

I. General information

NPI: 1760473607
Provider Name (Legal Business Name): SYLVIA MARIA CUPP LPC, LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-539-2644
  • Fax:
Mailing address:
  • Phone: 210-539-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number18909
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number9817
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: