Provider Demographics
NPI:1700977717
Name:KUBICEK, MARYANN (MFT)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:KUBICEK
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5318 E 2ND ST # 196
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5324
Mailing Address - Country:US
Mailing Address - Phone:562-986-7473
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST
Practice Address - Street 2:SUITE 550
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4519
Practice Address - Country:US
Practice Address - Phone:714-567-7636
Practice Address - Fax:714-834-6825
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35773106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist