Provider Demographics
NPI:1043200298
Name:HUBER, DEIRDRE J
Entity Type:Individual
Prefix:MS
First Name:DEIRDRE
Middle Name:J
Last Name:HUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:42581 ROUTE 6
Mailing Address - City:WYALUSING
Mailing Address - State:PA
Mailing Address - Zip Code:18853-0279
Mailing Address - Country:US
Mailing Address - Phone:570-746-3749
Mailing Address - Fax:570-746-0918
Practice Address - Street 1:42581 ROUTE 6
Practice Address - Street 2:
Practice Address - City:WYALUSING
Practice Address - State:PA
Practice Address - Zip Code:18853
Practice Address - Country:US
Practice Address - Phone:570-746-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYDC008031L111N00000X
NY9593111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018696930002Medicaid
929376OtherBCBS
813695OtherFIRST PRIORITY
813695OtherFIRST PRIORITY