Provider Demographics
NPI:1396909198
Name:KUBALA, MA IRISA HIBANADA (PT)
Entity type:Individual
Prefix:
First Name:MA IRISA
Middle Name:HIBANADA
Last Name:KUBALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 CREEKPOINTE TERRACE
Mailing Address - Street 2:APT 7
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-5908
Mailing Address - Country:US
Mailing Address - Phone:502-968-7867
Mailing Address - Fax:
Practice Address - Street 1:7823 OLD STATE ROAD 60
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1858
Practice Address - Country:US
Practice Address - Phone:812-246-4272
Practice Address - Fax:812-246-8136
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003464A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist