Provider Demographics
NPI:1710721246
Name:HUBBARD, DERION
Entity type:Individual
Prefix:
First Name:DERION
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 S OLIVER ST APT 509
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67210-1230
Mailing Address - Country:US
Mailing Address - Phone:316-347-3757
Mailing Address - Fax:
Practice Address - Street 1:815 N WACO AVE STE 35
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3928
Practice Address - Country:US
Practice Address - Phone:316-290-9046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171M00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator