Provider Demographics
NPI:1063482370
Name:LEIBOWITZ, GERALD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:LEIBOWITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 UTOPIA PKWY
Mailing Address - Street 2:1B
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1526
Mailing Address - Country:US
Mailing Address - Phone:347-395-9757
Mailing Address - Fax:718-465-4503
Practice Address - Street 1:5835 UTOPIA PKWY
Practice Address - Street 2:1B
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1526
Practice Address - Country:US
Practice Address - Phone:347-395-9757
Practice Address - Fax:718-465-4503
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003707-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7329861OtherGHI
NY93533Medicare ID - Type UnspecifiedGHI MEDICARE
NYV12801Medicare UPIN