Basic Information
| Provider Information | |||||||||
| NPI: | 1811366677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUBOSE | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | TERESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 BENDEN DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446912568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302649029 | ||||||||
| FaxNumber: | 3302637251 | ||||||||
| Practice Location | |||||||||
| Address1: | 299 CRAMER CREEK CT | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430172586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148895722 | ||||||||
| FaxNumber: | 6148899335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2015 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | S.1701335 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0297228 | 05 | OH | MEDICAID |