=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699561084
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEIDRA A HUBBARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2025
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E ARBOR VITAE ST APT 1
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90301-3573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-806-6277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2133
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90305-0133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-806-6277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------