Provider Demographics
NPI:1912439118
Name:HUBBARD, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
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 1:9912 LEVERNE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2241
Mailing Address - Country:US
Mailing Address - Phone:313-693-5486
Mailing Address - Fax:
Practice Address - Street 1:9912 LEVERNE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2241
Practice Address - Country:US
Practice Address - Phone:313-693-5486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities