Provider Demographics
NPI:1639482706
Name:DUBUQUE, LARRY JOE (PT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JOE
Last Name:DUBUQUE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4739 WILLIS AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2673
Mailing Address - Country:US
Mailing Address - Phone:916-717-2414
Mailing Address - Fax:
Practice Address - Street 1:500 W GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-2813
Practice Address - Country:US
Practice Address - Phone:818-637-2127
Practice Address - Fax:818-637-2126
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36882225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist