Provider Demographics
NPI:1780163501
Name:KUPERSMITH, CARLY MARIE
Entity type:Individual
Prefix:MS
First Name:CARLY
Middle Name:MARIE
Last Name:KUPERSMITH
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 1:310 20TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:IL
Mailing Address - Zip Code:61264-3365
Mailing Address - Country:US
Mailing Address - Phone:815-990-6803
Mailing Address - Fax:
Practice Address - Street 1:415 N RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-2044
Practice Address - Country:US
Practice Address - Phone:309-945-0625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist