Healthcare Provider Details

I. General information

NPI: 1407957384
Provider Name (Legal Business Name): JOHN DUBOSH LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE AVE
WYANDOTTE MI
48192-4668
US

IV. Provider business mailing address

1640 FORT ST STE D ATTN DENISE
TRENTON MI
48183-2040
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-6000
  • Fax:
Mailing address:
  • Phone: 734-391-3057
  • Fax: 734-391-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801062200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: