Provider Demographics
NPI:1164804142
Name:KUBON, TODD MICHAEL (BA, MAMS, CCA)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MICHAEL
Last Name:KUBON
Suffix:
Gender:M
Credentials:BA, MAMS, CCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 NUTTALL RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1804
Mailing Address - Country:US
Mailing Address - Phone:312-978-1073
Mailing Address - Fax:
Practice Address - Street 1:317 NUTTALL RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1804
Practice Address - Country:US
Practice Address - Phone:312-978-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL229N00000XOtherWPC CODE