Provider Demographics
NPI:1336810217
Name:HUBBERT, RAVEN M
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:M
Last Name:HUBBERT
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 1:4741 N 72ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4815
Mailing Address - Country:US
Mailing Address - Phone:414-982-8107
Mailing Address - Fax:
Practice Address - Street 1:4741 N 72ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4815
Practice Address - Country:US
Practice Address - Phone:414-982-8107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI83441842Medicaid