Healthcare Provider Details

I. General information

NPI: 1760375323
Provider Name (Legal Business Name): KEVIN KUPER BA, R-AAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 12TH AVE STE 100
LONGVIEW WA
98632-3820
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-8455
US

V. Phone/Fax

Practice location:
  • Phone: 360-200-5419
  • Fax: 844-612-6673
Mailing address:
  • Phone: 360-200-5419
  • Fax: 844-612-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61672117
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: