Provider Demographics
NPI:1083995955
Name:KUBELKA, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KUBELKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-4400
Mailing Address - Fax:
Practice Address - Street 1:209 9TH ST STE 302
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2235
Practice Address - Country:US
Practice Address - Phone:779-696-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005286235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.005286OtherSPEECH-LANGUAGE PATHOLOGIST