Provider Demographics
NPI:1780721803
Name:CUPPLES, SUSAN A (OTR)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:CUPPLES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6328 FAIRMOUNT AVE
Mailing Address - Street 2:STE 220
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3665
Mailing Address - Country:US
Mailing Address - Phone:510-525-2700
Mailing Address - Fax:510-525-2716
Practice Address - Street 1:6328 FAIRMOUNT AVE
Practice Address - Street 2:STE 220
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3665
Practice Address - Country:US
Practice Address - Phone:510-525-2700
Practice Address - Fax:510-525-2716
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7709171100000X
CA7191225X00000X
CA1051100260225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171100000XOther Service ProvidersAcupuncturist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29599ZOtherGRP ID
CAZZZ29723ZOtherGRP ID
ZZZ29731ZMedicare PIN
Q18412Medicare UPIN