Healthcare Provider Details

I. General information

NPI: 1245364983
Provider Name (Legal Business Name): MARK HUBER MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 NANTUCKET DR
JANESVILLE WI
53546-1763
US

IV. Provider business mailing address

3506 N US HIGHWAY 51
JANESVILLE WI
53545-0726
US

V. Phone/Fax

Practice location:
  • Phone: 608-752-5335
  • Fax:
Mailing address:
  • Phone: 608-757-5215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2519-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: