=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154711406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA MARTHA KUBISTA MA LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2015
-----------------------------------------------------
Last Update Date | 05/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 1ST ST NW
-----------------------------------------------------
City | CROSBY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56441-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-585-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15157 LADYSLIPPER LANE
-----------------------------------------------------
City | DEERWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56444-8918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-825-1021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 2613
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------