Provider Demographics
NPI:1164843017
Name:DUBOISE, KIRK
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:DUBOISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-3319
Mailing Address - Country:US
Mailing Address - Phone:479-785-4083
Mailing Address - Fax:479-668-2059
Practice Address - Street 1:615 N 19TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3319
Practice Address - Country:US
Practice Address - Phone:479-785-4083
Practice Address - Fax:479-668-2059
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)