Basic Information
| Provider Information | |||||||||
| NPI: | 1366740896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUPP | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | RILEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 823 | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435520823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194910420 | ||||||||
| FaxNumber: | 5676987875 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 INDIAN WOOD CIR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435374029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194910420 | ||||||||
| FaxNumber: | 5676987875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 867 | AK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 328261 | 05 | OH | MEDICAID |