Provider Demographics
NPI:1275933822
Name:KUBISCH, MARILYNN C (CAS II)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:C
Last Name:KUBISCH
Suffix:
Gender:F
Credentials:CAS II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17727 E CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-2634
Mailing Address - Country:US
Mailing Address - Phone:626-967-2677
Mailing Address - Fax:
Practice Address - Street 1:17727 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2634
Practice Address - Country:US
Practice Address - Phone:626-967-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-026961324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility