Provider Demographics
NPI:1427565928
Name:KUBASEK, MARYAM (LPC)
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:KUBASEK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10917 SHADOW GLEN DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-7800
Mailing Address - Country:US
Mailing Address - Phone:513-226-9538
Mailing Address - Fax:
Practice Address - Street 1:7570 BALES ST STE 380
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45069-7516
Practice Address - Country:US
Practice Address - Phone:513-226-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1700408101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health