Healthcare Provider Details

I. General information

NPI: 1154108868
Provider Name (Legal Business Name): KORTNI DUBOSE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MARTIN LUTHER KING JR DR
CLEVELAND OH
44104-3815
US

IV. Provider business mailing address

2801 MARTIN LUTHER KING JR DR
CLEVELAND OH
44104-3815
US

V. Phone/Fax

Practice location:
  • Phone: 216-448-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberP.08802
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP.08802
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: