MEDICARE: NICOLE DENISE KAZUBA LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0701010294	VA

General Provider Information

NPI Number	:	1053991885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DENISE KAZUBA LPC

Provider Business Mailing Address
First Line	:	278 CEDAR LN SE # 4048
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	703-975-6351
Fax Number	:

Provider Business Practice Location Address
First Line	:	278 CEDAR LN SE # 4048
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	703-975-6351
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	07/24/2023

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