Provider Demographics
NPI:1982697603
Name:DUBOSE, EDNA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:JEAN
Last Name:DUBOSE
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 1:2191 N AVENIDA DEL POLEN
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-4164
Mailing Address - Country:US
Mailing Address - Phone:520-625-9128
Mailing Address - Fax:
Practice Address - Street 1:2191 N AVENIDA DEL POLEN
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-4164
Practice Address - Country:US
Practice Address - Phone:520-625-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-28
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-01981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ139150Medicare UPIN