Healthcare Provider Details

I. General information

NPI: 1194388686
Provider Name (Legal Business Name): JUDITH ANNETTE HUBBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15765 KINGSLEY ROAD
NINILCHIK AK
99639
US

IV. Provider business mailing address

PO BOX 39368
NINILCHIK AK
99639-0368
US

V. Phone/Fax

Practice location:
  • Phone: 907-567-3970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4258
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: