Healthcare Provider Details

I. General information

NPI: 1003132135
Provider Name (Legal Business Name): CHARON DUBOSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 EXECUTIVE DR
HAMPTON VA
23666-2430
US

IV. Provider business mailing address

211 LARISSA DR
NEWPORT NEWS VA
23601-1426
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-1001
  • Fax:
Mailing address:
  • Phone: 757-952-5102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904007288
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: