MEDICARE: MRS. TIANA SHEVON KUBIK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1235454216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIANA SHEVON KUBIK

Provider Business Mailing Address
First Line	:	1346 W ESTES 1-S
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-5475
Country	:	US
Telephone Number	:	847-881-6775
Fax Number	:	248-671-0487

Provider Business Practice Location Address
First Line	:	1346 W ESTES 1-S
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-5475
Country	:	US
Telephone Number	:	847-881-6775
Fax Number	:	248-671-0487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	04/01/2010

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