Healthcare Provider Details

I. General information

NPI: 1518882562
Provider Name (Legal Business Name): NICOLE LADSON DUBOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30725 PYRAMID POINT DR
CANYON LAKE CA
92587-7501
US

IV. Provider business mailing address

30725 PYRAMID POINT DR
CANYON LAKE CA
92587-7501
US

V. Phone/Fax

Practice location:
  • Phone: 909-200-5911
  • Fax:
Mailing address:
  • Phone: 909-200-5911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: