Provider Demographics
NPI:1578960811
Name:HUBBARD, KENDALL
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
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 1:8145 LA RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-1604
Mailing Address - Country:US
Mailing Address - Phone:209-262-8127
Mailing Address - Fax:
Practice Address - Street 1:6147 SUTTER AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2738
Practice Address - Country:US
Practice Address - Phone:209-262-8127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI1424101YP2500X
CAIMF81397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional