MEDICARE: TAMARA LYNN KUBIAK LMFT

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	106H00000X	Marriage & Family Therapist	100389	CA

General Provider Information

NPI Number	:	1417513326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA LYNN KUBIAK LMFT

Provider Business Mailing Address
First Line	:	413 FLOWER ST
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2311
Country	:	US
Telephone Number	:	949-887-8020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 BRISTOL ST STE G201
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-7914
Country	:	US
Telephone Number	:	949-445-3160
Fax Number	:

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

Provider Enumeration Date	:	05/15/2019
Last Update Date	:	05/15/2019

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