Provider Demographics
NPI:1447972559
Name:CUBCUBAN, MISHELLE BUGTAI
Entity type:Individual
Prefix:
First Name:MISHELLE
Middle Name:BUGTAI
Last Name:CUBCUBAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BEAR OAK LN UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25306-6390
Mailing Address - Country:US
Mailing Address - Phone:304-601-8050
Mailing Address - Fax:
Practice Address - Street 1:298 TRICORN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25053-7148
Practice Address - Country:US
Practice Address - Phone:304-369-1385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist