Healthcare Provider Details

I. General information

NPI: 1477076719
Provider Name (Legal Business Name): KAYLA KUBISCHTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8285 SW NIMBUS AVE STE 148
BEAVERTON OR
97008-6465
US

IV. Provider business mailing address

8285 SW NIMBUS AVE STE 148
BEAVERTON OR
97008-6465
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax: 360-423-5086
Mailing address:
  • Phone: 503-352-3260
  • Fax: 503-352-3262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number60824144
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: