Provider Demographics
NPI:1215239520
Name:KLUBNIK, CYNTHIA ADELE (PHD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:ADELE
Last Name:KLUBNIK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-0455
Mailing Address - Country:US
Mailing Address - Phone:541-368-4313
Mailing Address - Fax:541-929-4967
Practice Address - Street 1:111 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9535
Practice Address - Country:US
Practice Address - Phone:541-368-4313
Practice Address - Fax:541-929-4967
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2203103TM1800X, 103TS0200X, 103TC2200X
TN1-11-8303103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
103I682739OtherMEDICARE