Provider Demographics
NPI:1184629164
Name:KUBAT, MICHAEL JAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAN
Last Name:KUBAT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 CHIPPING LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6802
Mailing Address - Country:US
Mailing Address - Phone:757-473-8656
Mailing Address - Fax:
Practice Address - Street 1:319 EDWIN DR
Practice Address - Street 2:STE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4541
Practice Address - Country:US
Practice Address - Phone:757-497-9545
Practice Address - Fax:757-497-8192
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040050751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8940525Medicaid
VA8940525Medicaid