Basic Information
Provider Information | |||||||||
NPI: | 1235100835 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUPKE | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1031 HIGH DUNES QUAY | ||||||||
Address2: | UNIT 105 | ||||||||
City: | HAMPTON | ||||||||
State: | VA | ||||||||
PostalCode: | 236641551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7577889282 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 620 JOHN PAUL JONES CIR | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | VA | ||||||||
PostalCode: | 237082111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7579537641 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2006 | ||||||||
LastUpdateDate: | 01/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 0810001380 | VA | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103T00000X | 0810001380 | VA | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.