Provider Demographics
NPI:1003707589
Name:RUPP, ALEX JOHN
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:JOHN
Last Name:RUPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-1605
Mailing Address - Country:US
Mailing Address - Phone:631-304-3374
Mailing Address - Fax:
Practice Address - Street 1:77 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-1605
Practice Address - Country:US
Practice Address - Phone:631-304-3374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician