Provider Demographics
NPI:1487068847
Name:STREET, JULIA AGNES
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:AGNES
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:AGNES
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:ATTN: BH FIT
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-3690
Mailing Address - Fax:907-543-1276
Practice Address - Street 1:460 RIDGECREST DRIVE SUITE 215
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-3690
Practice Address - Fax:907-543-1276
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1002573Medicaid