Provider Demographics
NPI:1861626178
Name:CUPPLES, MARY E
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CUPPLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:FIRST FLOOR NW BUILDING
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408-1424
Mailing Address - Country:US
Mailing Address - Phone:937-224-4646
Mailing Address - Fax:937-224-1625
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:FIRST FLOOR NW BUILDING
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1424
Practice Address - Country:US
Practice Address - Phone:937-224-4646
Practice Address - Fax:937-224-1625
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0004648101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health