Provider Demographics
NPI:1669614822
Name:CUPP, TARI D (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TARI
Middle Name:D
Last Name:CUPP
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:BERNIE
Mailing Address - State:MO
Mailing Address - Zip Code:63822-9457
Mailing Address - Country:US
Mailing Address - Phone:573-293-6256
Mailing Address - Fax:573-293-6256
Practice Address - Street 1:605 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:BERNIE
Practice Address - State:MO
Practice Address - Zip Code:63822-9457
Practice Address - Country:US
Practice Address - Phone:573-293-6256
Practice Address - Fax:573-293-6256
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465325801Medicaid