Provider Demographics
NPI:1083015804
Name:KUBAK, BRIETTA LISE (DPT)
Entity Type:Individual
Prefix:MS
First Name:BRIETTA
Middle Name:LISE
Last Name:KUBAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 SW MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1916
Mailing Address - Country:US
Mailing Address - Phone:503-227-7774
Mailing Address - Fax:503-227-7548
Practice Address - Street 1:1630 SW MORRISON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1916
Practice Address - Country:US
Practice Address - Phone:503-227-7774
Practice Address - Fax:503-227-7548
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60791225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty