1689765125 NPI number — MR. ROBERT K SHUPE LPC

Table of content: MR. ROBERT K SHUPE LPC (NPI 1689765125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689765125 NPI number — MR. ROBERT K SHUPE LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUPE
Provider First Name:
ROBERT
Provider Middle Name:
K
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689765125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3406 LARKSPUR LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILGORE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75662-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-704-8589
Provider Business Mailing Address Fax Number:
903-722-2624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1103 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75652-6077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-655-0123
Provider Business Practice Location Address Fax Number:
903-722-2624
Provider Enumeration Date:
09/28/2006

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: 101YM0800X , with the licence number:  16000 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 16000 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 123757 . This is a "CHIP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 840006 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 163211901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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