Basic Information
| Provider Information | |||||||||
| NPI: | 1659399673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBERT | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUBERT | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | CLAIRE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5467 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | KEEGO HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482100523 | ||||||||
| FaxNumber: | 5867530404 | ||||||||
| Practice Location | |||||||||
| Address1: | 5467 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | KEEGO HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482100523 | ||||||||
| FaxNumber: | 7344258350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801078103 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.