Healthcare Provider Details

I. General information

NPI: 1437711066
Provider Name (Legal Business Name): GWENDOLYN KUBOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 CENTER COURT DR STE 211
COVINA CA
91724-3668
US

IV. Provider business mailing address

1274 CENTER COURT DR STE 211
COVINA CA
91724-3668
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-4999
  • Fax:
Mailing address:
  • Phone: 626-339-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: