Provider Demographics
NPI:1770775819
Name:HUBBARD, KATHLEEN KEATON (PTA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:KEATON
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:KEATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:513 E CAPRI DR
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-9331
Mailing Address - Country:US
Mailing Address - Phone:573-358-7356
Mailing Address - Fax:573-358-7356
Practice Address - Street 1:513 E CAPRI DR
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-9331
Practice Address - Country:US
Practice Address - Phone:573-358-7356
Practice Address - Fax:573-358-7356
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist