Provider Demographics
NPI:1851707285
Name:HUBBARD, TAMIKA SHAVONNE (MSOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:SHAVONNE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAYNARD DR
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-2303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:429 JOHN F KENNEDY WAY STE 236
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-2118
Practice Address - Country:US
Practice Address - Phone:609-871-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013367225X00000X
NJ46TR00703900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist