Provider Demographics
NPI:1235670654
Name:LEIBOVITZ, TAHL ALEXANDER (LCSW)
Entity Type:Individual
Prefix:
First Name:TAHL
Middle Name:ALEXANDER
Last Name:LEIBOVITZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13340 87TH ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-1931
Mailing Address - Country:US
Mailing Address - Phone:718-924-6827
Mailing Address - Fax:
Practice Address - Street 1:13340 87TH ST APT 1
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-1975
Practice Address - Country:US
Practice Address - Phone:718-924-6827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0916881041C0700X
NY0916881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical