Provider Demographics
NPI:1437121803
Name:HUBBARD, MARY ELLEN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 WATSON RD
Mailing Address - Street 2:SUITE G101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1528
Mailing Address - Country:US
Mailing Address - Phone:314-367-5500
Mailing Address - Fax:314-843-9212
Practice Address - Street 1:109 N MILL ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1815
Practice Address - Country:US
Practice Address - Phone:636-937-2157
Practice Address - Fax:636-937-3172
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000172219101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO451501OtherHEALTHLINK
MO155602OtherBLUE CROSS