Provider Demographics
NPI:1043865173
Name:HUBBARD, SHIENIECE T (BS, HDFS)
Entity type:Individual
Prefix:
First Name:SHIENIECE
Middle Name:T
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:BS, HDFS
Other - Prefix:
Other - First Name:SHIENIECE
Other - Middle Name:T
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COUNSELOR
Mailing Address - Street 1:PO BOX 13201
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-0201
Mailing Address - Country:US
Mailing Address - Phone:443-366-0763
Mailing Address - Fax:614-983-3821
Practice Address - Street 1:2019 E GARDENIA DR
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-6018
Practice Address - Country:US
Practice Address - Phone:614-500-3548
Practice Address - Fax:614-983-3821
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 101YM0800X
OH103TA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH77117032Medicaid