Provider Demographics
NPI:1720293046
Name:STUPICH, MICHAEL C (MS CCC-A, FAAA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:STUPICH
Suffix:
Gender:M
Credentials:MS CCC-A, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3874
Mailing Address - Country:US
Mailing Address - Phone:920-206-8433
Mailing Address - Fax:920-262-0883
Practice Address - Street 1:615 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3874
Practice Address - Country:US
Practice Address - Phone:920-206-8433
Practice Address - Fax:920-262-0883
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41104100Medicaid
WI41104100Medicaid