Healthcare Provider Details

I. General information

NPI: 1265734552
Provider Name (Legal Business Name): JOHANNA CUBRA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 TILEY DR NE
ALBUQUERQUE NM
87110-1743
US

IV. Provider business mailing address

3215 TILEY DR NE
ALBUQUERQUE NM
87110-1743
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-3372
  • Fax:
Mailing address:
  • Phone: 505-573-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2175
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: