Provider Demographics
NPI:1295012722
Name:KUPHAL, GRACIA GERALDINE C (MA)
Entity type:Individual
Prefix:MRS
First Name:GRACIA
Middle Name:GERALDINE C
Last Name:KUPHAL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 NE 65TH ST # 82684
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6655
Mailing Address - Country:US
Mailing Address - Phone:971-456-4354
Mailing Address - Fax:503-741-8117
Practice Address - Street 1:7320 SW HUNZIKER RD STE 201
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:971-456-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA80865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist