1730428095 NPI number — KARLA OLDS SCHUPP

Table of content: KARLA OLDS SCHUPP (NPI 1730428095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730428095 NPI number — KARLA OLDS SCHUPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHUPP
Provider First Name:
KARLA
Provider Middle Name:
OLDS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HATCH
Provider Other First Name:
KARLA
Provider Other Middle Name:
SCHUPP
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730428095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 4TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARK
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57225-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-420-0536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 S BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201-4861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-818-0348
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8408163-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 801085901 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 4954 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)