Basic Information
Provider Information
NPI: 1033559901
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DUBOIS
FirstName: RAYMOND
MiddleName: MICHAEL
NamePrefix: MR.
NameSuffix:  
Credential: PTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 68 S MAIN ST
Address2:  
City: MARENGO
State: OH
PostalCode: 433349416
CountryCode: US
TelephoneNumber: 4192530708
FaxNumber:  
Practice Location
Address1: 327 W MAIN ST
Address2:  
City: CRESTLINE
State: OH
PostalCode: 448271434
CountryCode: US
TelephoneNumber: 4196833255
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/25/2013
LastUpdateDate: 06/25/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225200000XPTA. 08937OHY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


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