Provider Demographics
NPI:1114740263
Name:KUPHAL, OLIVIA (SLP)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:KUPHAL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:2600 S HERITAGE WOODS DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1408
Practice Address - Country:US
Practice Address - Phone:920-738-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6481154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist