Provider Demographics
NPI:1720134281
Name:KUPER, STACIE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:KUPER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3588 WEMBELY WAY
Mailing Address - Street 2:#105
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685
Mailing Address - Country:US
Mailing Address - Phone:918-812-5389
Mailing Address - Fax:
Practice Address - Street 1:10250 NW 53RD ST
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351
Practice Address - Country:US
Practice Address - Phone:954-746-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7394235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015504600Medicaid
OK200066340 AOtherDDSD WAIVER
FL015504600Medicaid