MEDICARE: DR. JAMES TODD DUBOSE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	71007252	IL

General Provider Information

NPI Number	:	1013133479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES TODD DUBOSE PH.D.

Provider Business Mailing Address
First Line	:	325 NORTH WELLS STREET
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60654
Country	:	US
Telephone Number	:	312-329-6694
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 MERCHANDISE MART PLZ
Second Line	:	SUITE 13-659, OFFICE # 1336
City	:	CHICAGO
State	:	IL
Zip	:	60654-1103
Country	:	US
Telephone Number	:	312-329-6694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	10/29/2010

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