Basic Information
| Provider Information | |||||||||
| NPI: | 1477867315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIBOVITZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2250 CHAPEL AVE W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 CHAPEL AVE W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 35SI00479300 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | B1-0000837 | DE | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0244627 | 05 | NJ | MEDICAID |