Provider Demographics
NPI:1932656600
Name:KUPPS, ERIN K (MS)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:K
Last Name:KUPPS
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 1:4647 CLYDE MORRIS BLVD UNIT 501
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-3001
Mailing Address - Country:US
Mailing Address - Phone:386-767-3752
Mailing Address - Fax:386-767-4319
Practice Address - Street 1:4647 CLYDE MORRIS BLVD UNIT 501
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-3001
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:386-767-4319
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLRBT-18-58540106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019602400Medicaid