MEDICARE: LISA N HUBBARD, PHD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1427522119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA N HUBBARD, PHD, LLC

Provider Business Mailing Address
First Line	:	5410 E COUNTY HIGHWAY 30A STE 205
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-6589
Country	:	US
Telephone Number	:	850-889-8869
Fax Number	:	850-296-8111

Provider Business Practice Location Address
First Line	:	5410 E COUNTY HIGHWAY 30A STE 205
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-6589
Country	:	US
Telephone Number	:	850-889-8869
Fax Number	:	850-296-8111

Authorized Official
Title or Position	:	LMHC
Name	:	DR. LISA N HUBBARD
Credential	:	DR.
Telephone Number	:	850-889-8896

Provider Enumeration Date	:	01/15/2019
Last Update Date	:	01/15/2019

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