Provider Demographics
NPI:1902278757
Name:DUBOIS, ELISSA ROSE (BCBA, MS)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:ROSE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:BCBA, MS
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:ROSE
Other - Last Name:LEIBL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 FREDA LN
Mailing Address - Street 2:
Mailing Address - City:CARDIFF BY THE SEA
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1107
Mailing Address - Country:US
Mailing Address - Phone:626-390-3759
Mailing Address - Fax:
Practice Address - Street 1:1650 FREDA LN
Practice Address - Street 2:
Practice Address - City:CARDIFF BY THE SEA
Practice Address - State:CA
Practice Address - Zip Code:92007-1107
Practice Address - Country:US
Practice Address - Phone:626-390-3759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-25978103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst