Healthcare Provider Details

I. General information

NPI: 1720293046
Provider Name (Legal Business Name): MICHAEL C STUPICH M.S. CCC-A, FAAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 12/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E MAIN ST
WATERTOWN WI
53094-3874
US

IV. Provider business mailing address

615 E MAIN ST
WATERTOWN WI
53094-3874
US

V. Phone/Fax

Practice location:
  • Phone: 920-206-8433
  • Fax: 920-262-0883
Mailing address:
  • Phone: 920-206-8433
  • Fax: 920-262-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number52156
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: