Provider Demographics
NPI:1336757566
Name:CUPP, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:CUPP
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 1:125 CRESTRIDGE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-942-3031
Mailing Address - Fax:
Practice Address - Street 1:2074 CUPOLA DR
Practice Address - Street 2:UNIT 300
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538
Practice Address - Country:US
Practice Address - Phone:970-227-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2024-10-31
Deactivation Date:2024-05-22
Deactivation Code:
Reactivation Date:2024-10-21
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COLPCC.0022109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator