Basic Information
| Provider Information | |||||||||
| NPI: | 1285370973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBOVCIK | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 MEMORIAL ST | ||||||||
| Address2: | |||||||||
| City: | DUNBAR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154311622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 W CRAWFORD AVE | ||||||||
| Address2: | |||||||||
| City: | CONNELLSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 154252538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246032657 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | SW137361 | 01 | PA | STATE LICENSE | OTHER |