Healthcare Provider Details

I. General information

NPI: 1902504145
Provider Name (Legal Business Name): LOURDES ODALYS CUPPLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21727 IH 10 W STE 108
SAN ANTONIO TX
78257-2108
US

IV. Provider business mailing address

21727 IH 10 W STE 108
SAN ANTONIO TX
78257-2108
US

V. Phone/Fax

Practice location:
  • Phone: 210-455-1091
  • Fax:
Mailing address:
  • Phone: 210-455-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-255983
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: