Healthcare Provider Details

I. General information

NPI: 1710721246
Provider Name (Legal Business Name): DERION HUBBARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N WACO AVE STE 35
WICHITA KS
67203-3928
US

IV. Provider business mailing address

2550 S OLIVER ST APT 509
WICHITA KS
67210-1230
US

V. Phone/Fax

Practice location:
  • Phone: 316-290-9046
  • Fax:
Mailing address:
  • Phone: 316-347-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: