Healthcare Provider Details

I. General information

NPI: 1992331318
Provider Name (Legal Business Name): NICOLE HUBBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 LINCOLN WAY
COEUR D ALENE ID
83814-2462
US

IV. Provider business mailing address

1607 LINCOLN WAY
COEUR D ALENE ID
83814-2462
US

V. Phone/Fax

Practice location:
  • Phone: 208-500-0567
  • Fax: 833-912-0110
Mailing address:
  • Phone: 208-500-0567
  • Fax: 833-912-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00012492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: