Basic Information
| Provider Information | |||||||||
| NPI: | 1699790907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUPPER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1917 1/2 WESTWOOD BLVD | ||||||||
| Address2: | STE 2 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900258400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104415537 | ||||||||
| FaxNumber: | 3104700863 | ||||||||
| Practice Location | |||||||||
| Address1: | 1917 1/2 WESTWOOD BLVD | ||||||||
| Address2: | STE 2 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900258400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108259989 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY14082 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | PSY140820 | 05 | CA | MEDICAID |