Provider Demographics
NPI:1205338076
Name:DUBAL, POONAM AVINASHI VINCHHI (LP, LSSP)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:AVINASHI VINCHHI
Last Name:DUBAL
Suffix:
Gender:
Credentials:LP, LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 GREENVILLE AVE STE 1050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-4084
Mailing Address - Country:US
Mailing Address - Phone:214-918-1999
Mailing Address - Fax:972-850-9452
Practice Address - Street 1:4925 GREENVILLE AVE STE 1050
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4084
Practice Address - Country:US
Practice Address - Phone:214-918-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70804103TS0200X
TX37360103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty