Basic Information
| Provider Information | |||||||||
| NPI: | 1922491901 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBILLA | ||||||||
| FirstName: | MARYCLARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 E BIDWELL ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E BIDWELL ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956303565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835915 | ||||||||
| FaxNumber: | 9169835906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2015 | ||||||||
| LastUpdateDate: | 03/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT9214 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OT9214 | 01 | CA | CA DEPT OF CONSUMER AFFAIRS | OTHER |