Provider Demographics
NPI:1790028330
Name:KUBIAK, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KUBIAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8200
Mailing Address - Fax:
Practice Address - Street 1:606 W SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48933-1032
Practice Address - Country:US
Practice Address - Phone:517-484-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087566104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker