Provider Demographics
NPI:1174656458
Name:HUBBARD, SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 VENTANA VILLAGE RD NW
Mailing Address - Street 2:VENTANA RANCH ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4183
Mailing Address - Country:US
Mailing Address - Phone:505-890-7375
Mailing Address - Fax:
Practice Address - Street 1:6801 VENTANA VILLAGE RD NW
Practice Address - Street 2:VENTANA RANCH ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4183
Practice Address - Country:US
Practice Address - Phone:505-890-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77470222Medicaid