Provider Demographics
NPI:1053476473
Name:TIBALDI, JOAN (LCSW, BCD)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:
Last Name:TIBALDI
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 COPPERHEAD CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2733
Mailing Address - Country:US
Mailing Address - Phone:904-679-4321
Mailing Address - Fax:
Practice Address - Street 1:612 COPPERHEAD CIR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2733
Practice Address - Country:US
Practice Address - Phone:904-679-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR205221041C0700X
FLSW156001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY37793OtherGHI PROVIDER #
NYN24801Medicare ID - Type Unspecified