Basic Information
| Provider Information | |||||||||
| NPI: | 1538284617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUBE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9192206971 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9192206971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2184 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2184 | 01 | NC | PT ASSISTANT LICENSE | OTHER |