Provider Demographics
NPI:1013133479
Name:DUBOSE, JAMES TODD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TODD
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 NORTH WELLS STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654
Mailing Address - Country:US
Mailing Address - Phone:312-329-6694
Mailing Address - Fax:
Practice Address - Street 1:222 MERCHANDISE MART PLZ
Practice Address - Street 2:SUITE 13-659, OFFICE # 1336
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-1103
Practice Address - Country:US
Practice Address - Phone:312-329-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71007252103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK44691Medicare PIN