Provider Demographics
NPI:1689075673
Name:DUBOSE, DEBRA (MSW LICENSED CLINICA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:MSW LICENSED CLINICA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 N PACE BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-6032
Mailing Address - Country:US
Mailing Address - Phone:850-723-0042
Mailing Address - Fax:
Practice Address - Street 1:1720 N PACE BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-6032
Practice Address - Country:US
Practice Address - Phone:850-723-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL47-1121769171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 4505OtherSTATE OF FLORIDA DEPARMENT OF HEALTH