Provider Demographics
NPI:1063290773
Name:KUBICEK, KENNETH (PHD, LCPC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KUBICEK
Suffix:
Gender:M
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OAK DR STE B
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5635
Mailing Address - Country:US
Mailing Address - Phone:618-972-1568
Mailing Address - Fax:618-205-3561
Practice Address - Street 1:3 OAK DR STE B
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5635
Practice Address - Country:US
Practice Address - Phone:618-972-1568
Practice Address - Fax:618-205-3561
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.002041103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist