Provider Demographics
NPI:1265907893
Name:HUBBARD, RAYMOND WINSTON
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:WINSTON
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 E WEST MAPLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 E WEST MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3571
Practice Address - Country:US
Practice Address - Phone:248-313-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health