Provider Demographics
NPI:1265411565
Name:KUBIZNA, TREY J (DPT)
Entity type:Individual
Prefix:
First Name:TREY
Middle Name:J
Last Name:KUBIZNA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 HOAG AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9632
Mailing Address - Country:US
Mailing Address - Phone:616-262-7263
Mailing Address - Fax:616-365-9394
Practice Address - Street 1:3035 HOAG AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9632
Practice Address - Country:US
Practice Address - Phone:616-262-7263
Practice Address - Fax:616-365-9394
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6946225100000X
MI5501012424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D116680OtherBCBS PROVIDER NUMBER
MI650D116680OtherBCBS PROVIDER NUMBER