Provider Demographics
NPI:1649934811
Name:DUBOSE, NIKKI (CEDRC, PSYD STUDENT)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:CEDRC, PSYD STUDENT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:N
Other - Last Name:DUBOSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4519 ENSENADA DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-5410
Mailing Address - Country:US
Mailing Address - Phone:310-747-5855
Mailing Address - Fax:
Practice Address - Street 1:4519 ENSENADA DR
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-5410
Practice Address - Country:US
Practice Address - Phone:310-747-5855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program