Basic Information
| Provider Information | |||||||||
| NPI: | 1912359043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKUPIEN | ||||||||
| FirstName: | REX | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493047984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317455045 | ||||||||
| FaxNumber: | 2317455031 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 E WILCOX AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE CLOUD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493498794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316895943 | ||||||||
| FaxNumber: | 2316891590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2016 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301016756 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.