Provider Demographics
NPI:1497425870
Name:SHUPP, MICHAEL G
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:SHUPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CONCORD GREENE UNIT 4
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3177
Mailing Address - Country:US
Mailing Address - Phone:817-734-9252
Mailing Address - Fax:
Practice Address - Street 1:7816 HIDDEN OAKS DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-3409
Practice Address - Country:US
Practice Address - Phone:817-734-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional