MEDICARE: KRISTINE KUPCHA MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		VT

General Provider Information

NPI Number	:	1174993273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINE KUPCHA MA

Provider Business Mailing Address
First Line	:	1016 2ND AVE N STE 203C
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3288
Country	:	US
Telephone Number	:
Fax Number	:	802-888-6393

Provider Business Practice Location Address
First Line	:	1016 2ND AVE N STE 203C
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3288
Country	:	US
Telephone Number	:	802-363-6188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2015
Last Update Date	:	04/05/2023

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