Provider Demographics
NPI:1740408871
Name:KUBACKY, GRETCHEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:
Last Name:KUBACKY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10883 ARIZONA AVE.
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232
Mailing Address - Country:US
Mailing Address - Phone:310-625-6083
Mailing Address - Fax:
Practice Address - Street 1:10883 ARIZONA AVE.
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232
Practice Address - Country:US
Practice Address - Phone:310-625-6083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21917103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist