Provider Demographics
NPI:1770096059
Name:DUBANEWICZ, MICHAEL JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DUBANEWICZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N FLAGLER DR STE P300
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-4326
Mailing Address - Country:US
Mailing Address - Phone:516-444-7336
Mailing Address - Fax:
Practice Address - Street 1:515 N FLAGLER DR STE P300
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401
Practice Address - Country:US
Practice Address - Phone:516-444-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0109761101Y00000X
VT097.0134512101Y00000X
FL328621132700000X
WANU60822507133N00000X
IA126925133N00000X
FLTPND410133N00000X
DEDH-0000022133N00000X
IN37003841A133N00000X
NMNDP-2023-0038133N00000X
UT13420040-4901133N00000X
VT074.0134403133N00000X
FL13123901171400000X
FLP00190175T00000X
ID5861763175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopath
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No171400000XOther Service ProvidersHealth & Wellness Coach
No175T00000XOther Service ProvidersPeer Specialist