Basic Information
| Provider Information | |||||||||
| NPI: | 1538834940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUBACEK | ||||||||
| FirstName: | SAGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232425000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3031 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900073033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233732400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2021 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | 127854 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.