Provider Demographics
NPI:1821247628
Name:KUBOUSHEK, KATIE M (AUD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:KUBOUSHEK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4227
Practice Address - Country:US
Practice Address - Phone:734-936-5730
Practice Address - Fax:734-615-4227
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0487231H00000X
MI1601000551231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0487OtherKY STATE LICENSE
12138438OtherCERTIFICATION NUMBER