Healthcare Provider Details

I. General information

NPI: 1154711406
Provider Name (Legal Business Name): TANYA MARTHA KUBISTA MA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14091 BAXTER DR STE 112
BAXTER MN
56425-8703
US

IV. Provider business mailing address

15157 LADYSLIPPER LN
DEERWOOD MN
56444-8918
US

V. Phone/Fax

Practice location:
  • Phone: 218-585-2052
  • Fax:
Mailing address:
  • Phone: 218-825-1021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2613
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: