Provider Demographics
NPI:1871957365
Name:DUBOSE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 STODDARD RD STE 600
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9041
Mailing Address - Country:US
Mailing Address - Phone:209-543-1874
Mailing Address - Fax:209-543-1869
Practice Address - Street 1:5815 STODDARD RD STE 600
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9041
Practice Address - Country:US
Practice Address - Phone:209-543-1874
Practice Address - Fax:209-543-1869
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA117273106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program