Provider Demographics
NPI:1518293364
Name:DUBOIS, PRISCILLA T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:T
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15030 S RAVINIA AVE
Mailing Address - Street 2:SUITE 30
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3256
Mailing Address - Country:US
Mailing Address - Phone:708-590-6833
Mailing Address - Fax:708-590-6804
Practice Address - Street 1:15030 S RAVINIA AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3256
Practice Address - Country:US
Practice Address - Phone:708-590-6833
Practice Address - Fax:708-590-6804
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007575103TC0700X
IN20042280A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical