Provider Demographics
NPI:1639815095
Name:KUBICEK, GLORY
Entity type:Individual
Prefix:
First Name:GLORY
Middle Name:
Last Name:KUBICEK
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:PO BOX 23741
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95153-3741
Mailing Address - Country:US
Mailing Address - Phone:765-315-5785
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 23741
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95153-3741
Practice Address - Country:US
Practice Address - Phone:765-315-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
CA125811104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No156F00000XEye and Vision Services ProvidersTechnician/Technologist