Provider Demographics
NPI:1669760229
Name:HUBBARD, ANDREA CARL
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:CARL
Last Name:HUBBARD
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:PO BOX 2387
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-2387
Mailing Address - Country:US
Mailing Address - Phone:276-393-7670
Mailing Address - Fax:
Practice Address - Street 1:11506 NICHOLAS ST
Practice Address - Street 2:SUITE 110
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4407
Practice Address - Country:US
Practice Address - Phone:877-230-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006384235Z00000X
TN4110235Z00000X
FLSA10497235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist