Provider Demographics
NPI:1871069914
Name:KUPSTAS, MATTHEW (OTR/L)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KUPSTAS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3751
Mailing Address - Country:US
Mailing Address - Phone:410-693-8353
Mailing Address - Fax:
Practice Address - Street 1:4012 HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-8372
Practice Address - Country:US
Practice Address - Phone:828-212-0256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12147225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist