=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205621240
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MINDY KUBRIN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2025
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 ELM ST STE 3
-----------------------------------------------------
City | NEW CANAAN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06840-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-360-2638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 87 FULLING MILL LN
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06877-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-360-2638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4403
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------