Provider Demographics
NPI:1124008511
Name:LIBON, DAVID J (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:LIBON
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 1:42 E LAUREL RD STE 1800-A
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-6843
Mailing Address - Fax:856-566-6419
Practice Address - Street 1:42 E LAUREL RD STE 1800-A
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:856-566-6419
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSI00271600103T00000X
NJ35SI00271600103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8958904Medicaid
NJ477291MXIMedicare PIN
NJ8958904Medicaid