Healthcare Provider Details

I. General information

NPI: 1124424551
Provider Name (Legal Business Name): ADDIE HUBBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ADDIE BURNHAM

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 CENTER DR
RICHMOND KY
40475-3841
US

IV. Provider business mailing address

109 WIND HAVEN DR STE 100
NICHOLASVILLE KY
40356-8010
US

V. Phone/Fax

Practice location:
  • Phone: 859-224-2273
  • Fax: 859-224-4675
Mailing address:
  • Phone: 859-224-2273
  • Fax: 859-224-4675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberR4856
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number131129
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: