Provider Demographics
NPI:1649303454
Name:HAUBOLD, LINDA KUKUK (PHD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:KUKUK
Last Name:HAUBOLD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:SUSAN
Other - Last Name:KUKUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3045 OJIBWA TRAIL
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-947-7082
Mailing Address - Fax:231-947-1911
Practice Address - Street 1:1139 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-947-7082
Practice Address - Fax:231-947-1911
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008535103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680B83299OtherBLUE CROSS BS