Provider Demographics
NPI:1447700950
Name:KUBACKI, MELISSA ELIZABETH (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ELIZABETH
Last Name:KUBACKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ELIZABETH
Other - Last Name:ECKELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-C
Mailing Address - Street 1:8205 MAIN ST STE 1-02
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6053
Mailing Address - Country:US
Mailing Address - Phone:202-236-9090
Mailing Address - Fax:716-408-1649
Practice Address - Street 1:2790 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2704
Practice Address - Country:US
Practice Address - Phone:716-931-9037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0946171041C0700X
WALW607018041041C0700X
MD256371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid