Provider Demographics
NPI:1023505146
Name:HUBBARD, KEVIN JUSTIN (LPC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JUSTIN
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24-4 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-5414
Mailing Address - Country:US
Mailing Address - Phone:484-682-5615
Mailing Address - Fax:
Practice Address - Street 1:3900 FORD RD STE E
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2001
Practice Address - Country:US
Practice Address - Phone:267-908-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC010091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty