Basic Information
| Provider Information | |||||||||
| NPI: | 1164986261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBERT | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEPHERD | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 249 W CORAL DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810071790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413143187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 304 INVERNESS WAY S STE 125 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801125820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037591342 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2019 | ||||||||
| LastUpdateDate: | 01/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-59702 | CO | Y |
No ID Information.