Basic Information
| Provider Information | |||||||||
| NPI: | 1720012081 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUBERMAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 1/2 NINITA STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 PASEO DE PERALTA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | 5058201209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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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 | 101YA0400X | 005712 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 4182 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 000B6003 | 05 | NM | MEDICAID |