Basic Information
| Provider Information | |||||||||
| NPI: | 1568063154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBOSE | ||||||||
| FirstName: | CLESHAUN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9375 E SHEA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772071144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4131 N 24TH ST STE B102 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850166231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808824545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2020 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LAC-19354 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.