Healthcare Provider Details

I. General information

NPI: 1336810217
Provider Name (Legal Business Name): RAVEN M HUBBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2902 W ROOSEVELT DR
MILWAUKEE WI
53216-1838
US

IV. Provider business mailing address

2902 W ROOSEVELT DR
MILWAUKEE WI
53216-1838
US

V. Phone/Fax

Practice location:
  • Phone: 414-982-8107
  • Fax:
Mailing address:
  • Phone: 414-982-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0021059
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: