Healthcare Provider Details

I. General information

NPI: 1578744686
Provider Name (Legal Business Name): SUSAN DICKES HUBBARD L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 KALMIA AVE
BOULDER CO
80304-1740
US

IV. Provider business mailing address

810 KALMIA AVE
BOULDER CO
80304-1740
US

V. Phone/Fax

Practice location:
  • Phone: 303-447-1893
  • Fax: 303-443-2291
Mailing address:
  • Phone: 303-447-1893
  • Fax: 303-443-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number876143
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: