Provider Demographics
NPI:1861711533
Name:KUBASTA, CARRIE F (CSAC,SW)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:F
Last Name:KUBASTA
Suffix:
Gender:F
Credentials:CSAC,SW
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:F
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1095 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1115
Mailing Address - Country:US
Mailing Address - Phone:920-720-3700
Mailing Address - Fax:920-720-3806
Practice Address - Street 1:1095 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1115
Practice Address - Country:US
Practice Address - Phone:920-720-2300
Practice Address - Fax:920-720-3719
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15318101YA0400X
WI8289104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker