Provider Demographics
NPI:1750524021
Name:STUPAVSKY, CHRISTINE M
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:STUPAVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 HIGHWAY 96 S
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:IL
Mailing Address - Zip Code:62360-2504
Mailing Address - Country:US
Mailing Address - Phone:217-242-8332
Mailing Address - Fax:573-221-2123
Practice Address - Street 1:3700 HIGHWAY MM
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-3602
Practice Address - Country:US
Practice Address - Phone:573-221-2111
Practice Address - Fax:573-221-2123
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010018153101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional