Provider Demographics
NPI:1841312428
Name:KUBOUSEK, LYNN GAEBE (PT)
Entity type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:GAEBE
Last Name:KUBOUSEK
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 1:115 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-2503
Mailing Address - Country:US
Mailing Address - Phone:701-352-3091
Mailing Address - Fax:701-352-1270
Practice Address - Street 1:2400 47TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3405
Practice Address - Country:US
Practice Address - Phone:701-746-2230
Practice Address - Fax:701-746-2475
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND58770Medicaid