Basic Information
| Provider Information | |||||||||
| NPI: | 1699073353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBUQUE | ||||||||
| FirstName: | ERICK | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA-D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 145 CORAL AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402062017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752256980 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1405 E BURNETT AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880724 | ||||||||
| FaxNumber: | 5025880721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2011 | ||||||||
| LastUpdateDate: | 01/13/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | BCBA# 1-08-4322 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.