MEDICARE: DR. STEVEN R. KUBACKI PH.D.

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	103TC0700X	Clinical Psychologist	2316	WA

General Provider Information

NPI Number	:	1356421465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEVEN R. KUBACKI PH.D.

Provider Business Mailing Address
First Line	:	3418 NE 65TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-7341
Country	:	US
Telephone Number	:	206-235-9393
Fax Number	:	206-517-8123

Provider Business Practice Location Address
First Line	:	3418 NE 65TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-7341
Country	:	US
Telephone Number	:	206-235-9393
Fax Number	:	206-517-8123

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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