Provider Demographics
NPI:1891832655
Name:HUBBARD, ERICA ANNE (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:ANNE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:ANNE
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSCCC-SLP
Mailing Address - Street 1:2251 S BAYOU BAR WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4519
Mailing Address - Country:US
Mailing Address - Phone:208-887-6370
Mailing Address - Fax:
Practice Address - Street 1:890 N COLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8638
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:208-323-8889
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1470235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09129978OtherASHA
IDSP979OtherBLUE CROSS INSURANCE