Healthcare Provider Details

I. General information

NPI: 1891067195
Provider Name (Legal Business Name): SANDRA KUBACKI DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2498 DAYTON XENIA RD
BEAVERCREEK OH
45434-7169
US

IV. Provider business mailing address

2498 DAYTON XENIA RD
BEAVERCREEK OH
45434-7169
US

V. Phone/Fax

Practice location:
  • Phone: 937-427-1919
  • Fax: 937-427-1949
Mailing address:
  • Phone: 937-427-1919
  • Fax: 937-427-1949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT013205
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: