Provider Demographics
NPI:1407363237
Name:HUBBARD, COREY ELIZABETH
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ELIZABETH
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 S CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-4115
Mailing Address - Country:US
Mailing Address - Phone:206-214-7317
Mailing Address - Fax:
Practice Address - Street 1:218 S 38TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7807
Practice Address - Country:US
Practice Address - Phone:206-313-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid