Provider Demographics
NPI:1982790465
Name:KUBNICK, BETHANY ROSE (PT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:KUBNICK
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 1:3501 CRANBERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-5213
Mailing Address - Country:US
Mailing Address - Phone:715-393-1000
Mailing Address - Fax:
Practice Address - Street 1:3501 CRANBERRY BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5213
Practice Address - Country:US
Practice Address - Phone:715-393-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10223-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40460100Medicaid