Provider Demographics
NPI:1407340078
Name:KUBISTEK, SHADENE R (AUD)
Entity Type:Individual
Prefix:
First Name:SHADENE
Middle Name:R
Last Name:KUBISTEK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SHADENE
Other - Middle Name:RUTH
Other - Last Name:PAINTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:2580 HAYMAKER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3500
Mailing Address - Country:US
Mailing Address - Phone:412-372-3336
Mailing Address - Fax:412-372-2004
Practice Address - Street 1:2580 HAYMAKER RD STE 105
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3500
Practice Address - Country:US
Practice Address - Phone:412-372-3336
Practice Address - Fax:412-372-2004
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT001126L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11228191OtherCAQH
PA103570822Medicaid