Provider Demographics
NPI:1942697586
Name:KUBLY, LAURA;
Entity Type:Individual
Prefix:
First Name:LAURA;
Middle Name:
Last Name:KUBLY
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 1:2188 SW PARK PL
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1100
Mailing Address - Country:US
Mailing Address - Phone:503-568-1390
Mailing Address - Fax:
Practice Address - Street 1:2188 SW PARK PL
Practice Address - Street 2:SUITE 10
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1100
Practice Address - Country:US
Practice Address - Phone:503-568-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21141225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist