Provider Demographics
NPI:1124896014
Name:KORUBA, NICOLAI STONE (GD)
Entity type:Individual
Prefix:MR
First Name:NICOLAI
Middle Name:STONE
Last Name:KORUBA
Suffix:
Gender:M
Credentials:GD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23909 W RENWICK RD STE 105
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2109
Mailing Address - Country:US
Mailing Address - Phone:779-234-9583
Mailing Address - Fax:
Practice Address - Street 1:23909 W RENWICK RD STE 105
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2109
Practice Address - Country:US
Practice Address - Phone:779-234-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician