Provider Demographics
NPI:1275597395
Name:HUBBARD, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SE KANE STREET
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8936
Mailing Address - Country:US
Mailing Address - Phone:541-673-0057
Mailing Address - Fax:541-673-2270
Practice Address - Street 1:770 SE KANE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3943
Practice Address - Country:US
Practice Address - Phone:541-673-0057
Practice Address - Fax:541-673-2270
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL45251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
009274007Medicare ID - Type Unspecified
S82930Medicare UPIN