Provider Demographics
NPI:1285045203
Name:CUPP, TAMMY (LPCC, LICDC)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:
Last Name:CUPP
Suffix:
Gender:F
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:BLAKESLEE
Mailing Address - State:OH
Mailing Address - Zip Code:43505-0182
Mailing Address - Country:US
Mailing Address - Phone:419-633-7489
Mailing Address - Fax:419-636-3100
Practice Address - Street 1:433 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1690
Practice Address - Country:US
Practice Address - Phone:419-636-1131
Practice Address - Fax:419-636-3100
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE170024101YP2500X, 101YP2500X
OH161426101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0183607Medicaid