Healthcare Provider Details

I. General information

NPI: 1306288899
Provider Name (Legal Business Name): AMY ELIZABETH KUPPER MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11311 BRIDGEPORT WAY SW STE 309
LAKEWOOD WA
98499-3078
US

IV. Provider business mailing address

11311 BRIDGEPORT WAY SW STE 309
LAKEWOOD WA
98499-3078
US

V. Phone/Fax

Practice location:
  • Phone: 253-985-2949
  • Fax: 206-933-1047
Mailing address:
  • Phone: 253-985-2949
  • Fax: 206-933-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60803628
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: