Provider Demographics
NPI:1487168779
Name:KUPSICK, TED
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:KUPSICK
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 1:1637 TROTTERS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STANFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:28163-9310
Mailing Address - Country:US
Mailing Address - Phone:704-244-1490
Mailing Address - Fax:
Practice Address - Street 1:401 LAMBERT RD
Practice Address - Street 2:
Practice Address - City:BISCOE
Practice Address - State:NC
Practice Address - Zip Code:27209-9002
Practice Address - Country:US
Practice Address - Phone:910-428-2117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5124225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant