Provider Demographics
NPI:1285014654
Name:DUBOIS, KAILIE (MS)
Entity Type:Individual
Prefix:
First Name:KAILIE
Middle Name:
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KAILIE
Other - Middle Name:
Other - Last Name:ASAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1232 MARILYN LN
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-7689
Mailing Address - Country:US
Mailing Address - Phone:248-564-8453
Mailing Address - Fax:
Practice Address - Street 1:1232 MARILYN LN
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34286-7689
Practice Address - Country:US
Practice Address - Phone:248-564-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
MO252Y00000X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No252Y00000XAgenciesEarly Intervention Provider Agency