Provider Demographics
NPI:1073804704
Name:KUPSTAS, AMY B (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:B
Last Name:KUPSTAS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 YATES ST
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4118
Mailing Address - Country:US
Mailing Address - Phone:570-690-0623
Mailing Address - Fax:
Practice Address - Street 1:11850 NICHOLAS ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4476
Practice Address - Country:US
Practice Address - Phone:402-505-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006778224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant