Provider Demographics
NPI:1770857674
Name:MCCUBBINS, MISTY B (MS CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:B
Last Name:MCCUBBINS
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3932 SWEETSPIRE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-4058
Mailing Address - Country:US
Mailing Address - Phone:502-827-4412
Mailing Address - Fax:
Practice Address - Street 1:3932 SWEETSPIRE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40514-4058
Practice Address - Country:US
Practice Address - Phone:502-827-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2013-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-3106235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK106030Medicare PIN