Healthcare Provider Details

I. General information

NPI: 1265615843
Provider Name (Legal Business Name): BRENT A. CUPP MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 S 13TH ST
TACOMA WA
98402-1908
US

IV. Provider business mailing address

245 TACOMA AVE S #103
TACOMA WA
98402-2500
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-5000
  • Fax:
Mailing address:
  • Phone: 360-580-1938
  • Fax: 253-383-5548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: