Provider Demographics
NPI:1477854073
Name:DUBOIS, DOMINIQUE PAGE (LCSW)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:PAGE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 S MACADAM AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3564
Mailing Address - Country:US
Mailing Address - Phone:503-477-7878
Mailing Address - Fax:
Practice Address - Street 1:12790 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1552
Practice Address - Country:US
Practice Address - Phone:503-328-1512
Practice Address - Fax:503-238-2436
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL67711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid