Provider Demographics
NPI:1851455455
Name:KUBICKI, ELAINE MARLENE
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARLENE
Last Name:KUBICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:MARLENE
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, CADCIII
Mailing Address - Street 1:4245 S WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-6217
Mailing Address - Country:US
Mailing Address - Phone:262-786-0888
Mailing Address - Fax:
Practice Address - Street 1:1025 S MOORLAND RD STE 403
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6945
Practice Address - Country:US
Practice Address - Phone:262-786-0411
Practice Address - Fax:262-786-9954
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI887-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional