Provider Demographics
NPI:1508461328
Name:HUTT, ANNALYCIA VICTORIA
Entity Type:Individual
Prefix:
First Name:ANNALYCIA
Middle Name:VICTORIA
Last Name:HUTT
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 1:1536 MOORLAND DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6675
Mailing Address - Country:US
Mailing Address - Phone:916-897-3289
Mailing Address - Fax:
Practice Address - Street 1:3517 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4026
Practice Address - Country:US
Practice Address - Phone:619-955-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 172V00000X
CAMPSS-BGEYNR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker