Provider Demographics
NPI:1023034659
Name:DUBBELD, KEY JACKLYN (MS-SLP)
Entity Type:Individual
Prefix:
First Name:KEY
Middle Name:JACKLYN
Last Name:DUBBELD
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3364 ANTIGUA LN
Mailing Address - Street 2:UNIT 102
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2240
Mailing Address - Country:US
Mailing Address - Phone:813-915-1171
Mailing Address - Fax:813-932-6368
Practice Address - Street 1:3364 ANTIGUA LN
Practice Address - Street 2:UNIT 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2240
Practice Address - Country:US
Practice Address - Phone:813-915-1171
Practice Address - Fax:813-932-6368
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888663600Medicaid
FL888663698Medicaid
FL888663696Medicaid