Provider Demographics
NPI:1205311347
Name:CUPP, TIARRA SHAFER (BCBA)
Entity type:Individual
Prefix:
First Name:TIARRA
Middle Name:SHAFER
Last Name:CUPP
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 OAKVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-1329
Mailing Address - Country:US
Mailing Address - Phone:860-941-5960
Mailing Address - Fax:
Practice Address - Street 1:85 STONEHEIGHTS DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1975
Practice Address - Country:US
Practice Address - Phone:860-333-5183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-18-32304103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst