MEDICARE: SHAREE NICOLE CUPP SLP ASSISTANT

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	2355S0801X	Speech-Language Assistant	36165	TX

General Provider Information

NPI Number	:	1316571003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAREE NICOLE CUPP SLP ASSISTANT

Provider Business Mailing Address
First Line	:	4351 FM 1195
Second Line	:
City	:	MINERAL WELLS
State	:	TX
Zip	:	76067-0731
Country	:	US
Telephone Number	:	940-745-0286
Fax Number	:

Provider Business Practice Location Address
First Line	:	6530 HAWKS CREEK CT STE 107
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1164
Country	:	US
Telephone Number	:	817-435-4631
Fax Number	:

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

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	03/03/2020

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