Provider Demographics
NPI:1356579932
Name:DUQUE, LUIS (NCSP)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:DUQUE
Suffix:
Gender:M
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 VFW PARKWAY
Mailing Address - Street 2:SUITE # 19
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4309
Mailing Address - Country:US
Mailing Address - Phone:617-970-3002
Mailing Address - Fax:
Practice Address - Street 1:1212 VFW PKWY
Practice Address - Street 2:SUITE # 19
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4309
Practice Address - Country:US
Practice Address - Phone:617-970-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA377754103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
38039OtherNCSP--NATIONALLY CERTIFIED SCHOOL PSYCHOLOGIST
MA377754OtherDEPARTMENT OF EDUCATION--LIC SCH PSYCHOLOGIST