Basic Information
| Provider Information | |||||||||
| NPI: | 1194195024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBOSE | ||||||||
| FirstName: | SONIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LSW, CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARES DUBOSE | ||||||||
| OtherFirstName: | SONIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600852321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778296 | ||||||||
| FaxNumber: | 8479845639 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 N COUNTY ST | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600854220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475612783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 36580 | IL | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 150.108061 | IL | N | Behavioral Health & Social Service Providers | Social Worker | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | 150.108061 | IL | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.