Provider Demographics
NPI:1922645647
Name:DUPUCH, CEDRIC JR
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:DUPUCH
Suffix:JR
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 1:201 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5524
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0Medicaid