=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659799211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA HUEBNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2014
-----------------------------------------------------
Last Update Date | 08/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 TUTTLE AVE
-----------------------------------------------------
City | EASTPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11941-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-801-3057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 COLUMBINE AVE N
-----------------------------------------------------
City | HAMPTON BAYS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11946-4122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-980-2847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 022120-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------