Healthcare Provider Details

I. General information

NPI: 1700997137
Provider Name (Legal Business Name): LARRY CURTIS KUBIAK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 PHYSICIANS DR
TALLAHASSEE FL
32308-4619
US

IV. Provider business mailing address

5398 PEMBRIDGE PL
TALLAHASSEE FL
32309-6800
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-5879
  • Fax: 850-431-7478
Mailing address:
  • Phone: 850-668-9763
  • Fax: 850-431-7478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY0004011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: