=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700243086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUBOIS COUNSELING, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2016
-----------------------------------------------------
Last Update Date | 01/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 CHURCH ST SUITE 615
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-680-5620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9444 LAWNDALE AVE
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60203-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-680-5620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NATALIE E DUBOIS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 773-680-5620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149-002102
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------