Healthcare Provider Details

I. General information

NPI: 1568743037
Provider Name (Legal Business Name): NOELLE E CUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 DEXTER ST
NEW LONDON WI
54961-2522
US

IV. Provider business mailing address

1828 DEXTER ST
NEW LONDON WI
54961-2522
US

V. Phone/Fax

Practice location:
  • Phone: 920-982-4009
  • Fax:
Mailing address:
  • Phone: 920-982-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4802-027
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: