Provider Demographics
NPI:1790238053
Name:HUBBLE, AMANDA ROSE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:HUBBLE
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 1:634 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-4679
Mailing Address - Country:US
Mailing Address - Phone:636-352-8766
Mailing Address - Fax:
Practice Address - Street 1:634 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-4679
Practice Address - Country:US
Practice Address - Phone:636-352-8766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016027021225X00000X
PAOC014962225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist