Provider Demographics
NPI:1093719544
Name:HUBBARD, MOIRA A (PSY D)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:A
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2395 OAK VALLEY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-8943
Mailing Address - Country:US
Mailing Address - Phone:734-995-5181
Mailing Address - Fax:734-995-9011
Practice Address - Street 1:2395 OAK VALLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-8943
Practice Address - Country:US
Practice Address - Phone:734-995-5181
Practice Address - Fax:734-995-9011
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63001008483103TC0700X
CAPSY 22353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5735074OtherAETNA
MI5735074OtherAETNA
MI540159Medicare UPIN