Provider Demographics
NPI:1427462548
Name:KUBENA, MELISSA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:KUBENA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:832 1ST ST
Mailing Address - Street 2:STE 140
Mailing Address - City:NASHWAUK
Mailing Address - State:MN
Mailing Address - Zip Code:55769-1245
Mailing Address - Country:US
Mailing Address - Phone:218-885-1282
Mailing Address - Fax:218-885-1471
Practice Address - Street 1:832 1ST ST
Practice Address - Street 2:STE 140
Practice Address - City:NASHWAUK
Practice Address - State:MN
Practice Address - Zip Code:55769-1245
Practice Address - Country:US
Practice Address - Phone:218-885-1282
Practice Address - Fax:218-885-1471
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN130020300Medicaid
MN130020300Medicaid