Provider Demographics
NPI:1225478613
Name:KUBOTA, MAXIMILIAN MASAHITO
Entity Type:Individual
Prefix:
First Name:MAXIMILIAN
Middle Name:MASAHITO
Last Name:KUBOTA
Suffix:
Gender:M
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 511
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS REY
Mailing Address - State:CA
Mailing Address - Zip Code:92068-0511
Mailing Address - Country:US
Mailing Address - Phone:858-256-7986
Mailing Address - Fax:
Practice Address - Street 1:2244 FARADAY AVE STE 116
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-7208
Practice Address - Country:US
Practice Address - Phone:858-256-7986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99994106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist