Provider Demographics
NPI:1477076719
Name:KUBISCHTA, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:KUBISCHTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8285 SW NIMBUS AVE STE 148
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6465
Mailing Address - Country:US
Mailing Address - Phone:503-352-3260
Mailing Address - Fax:503-352-3262
Practice Address - Street 1:8285 SW NIMBUS AVE STE 148
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6465
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:360-423-5086
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60824144101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2098021Medicaid