Provider Demographics
NPI:1558877332
Name:DUBOIS, ROSE MEDGINE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MEDGINE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8016 80TH WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6781
Mailing Address - Country:US
Mailing Address - Phone:561-567-3114
Mailing Address - Fax:
Practice Address - Street 1:8016 80TH WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6781
Practice Address - Country:US
Practice Address - Phone:561-567-3114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-16
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FL1-22-59533103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist