Provider Demographics
NPI:1306288899
Name:KUPPER, AMY ELIZABETH (MS)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:KUPPER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW STE 309
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3078
Mailing Address - Country:US
Mailing Address - Phone:253-985-2949
Mailing Address - Fax:206-933-1047
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 309
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3078
Practice Address - Country:US
Practice Address - Phone:253-985-2949
Practice Address - Fax:206-933-1047
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60803628103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2099871Medicaid