Provider Demographics
NPI:1164804191
Name:CUPP, LEXIE JO (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LEXIE
Middle Name:JO
Last Name:CUPP
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17095 FENTON DEDEAUX RD
Mailing Address - Street 2:
Mailing Address - City:KILN
Mailing Address - State:MS
Mailing Address - Zip Code:39556-6931
Mailing Address - Country:US
Mailing Address - Phone:318-416-2208
Mailing Address - Fax:
Practice Address - Street 1:17095 FENTON DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:KILN
Practice Address - State:MS
Practice Address - Zip Code:39556-6931
Practice Address - Country:US
Practice Address - Phone:318-416-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-14174103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst