Provider Demographics
NPI:1407576432
Name:KUPECKI, TARA LYNN (MS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:KUPECKI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-2780
Mailing Address - Country:US
Mailing Address - Phone:631-445-6179
Mailing Address - Fax:
Practice Address - Street 1:495 FRANKLINVILLE RD.
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:NY
Practice Address - Zip Code:11948
Practice Address - Country:US
Practice Address - Phone:631-315-7173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist