Provider Demographics
NPI:1982078168
Name:KUBISTA, BRITTANY (COTA/L)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:KUBISTA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S BASQUE AVE
Mailing Address - Street 2:APT 9
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12881 KNOTT ST
Practice Address - Street 2:103
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-3925
Practice Address - Country:US
Practice Address - Phone:714-892-6828
Practice Address - Fax:714-898-9720
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3349224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant