Provider Demographics
NPI:1649284738
Name:HUPPERT, MICHAEL R (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:HUPPERT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9912 MOUNTAIN BERRY CT
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-9616
Mailing Address - Country:US
Mailing Address - Phone:757-234-0188
Mailing Address - Fax:
Practice Address - Street 1:12725 MCMANUS BLVD
Practice Address - Street 2:SUITE 2G
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4402
Practice Address - Country:US
Practice Address - Phone:757-874-1676
Practice Address - Fax:757-874-2226
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040002941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649284738Medicaid
VA1649284738Medicaid