MEDICARE: DR. ALTON CLARK DUBOIS 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	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1467538769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALTON CLARK DUBOIS PH.D.

Provider Business Mailing Address
First Line	:	4510 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3809
Country	:	US
Telephone Number	:	773-588-2658
Fax Number	:	773-478-0303

Provider Business Practice Location Address
First Line	:	4510 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3809
Country	:	US
Telephone Number	:	773-588-2658
Fax Number	:	773-478-0303

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

Provider Enumeration Date	:	10/29/2006
Last Update Date	:	07/08/2007

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