Provider Demographics
NPI:1023655032
Name:DUBOU, NICOLE JANINE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JANINE
Last Name:DUBOU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WESTBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3324
Mailing Address - Country:US
Mailing Address - Phone:502-415-9477
Mailing Address - Fax:
Practice Address - Street 1:1102 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5438
Practice Address - Country:US
Practice Address - Phone:781-848-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist