Provider Demographics
NPI:1407864549
Name:TREIBLE, JONATHAN L WILSON (PHD ABPP)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L WILSON
Last Name:TREIBLE
Suffix:
Gender:M
Credentials:PHD ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-0443
Mailing Address - Country:US
Mailing Address - Phone:716-480-1997
Mailing Address - Fax:716-464-4951
Practice Address - Street 1:719 ENGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-2406
Practice Address - Country:US
Practice Address - Phone:716-480-1947
Practice Address - Fax:716-464-4951
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0078691103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003163Medicare ID - Type UnspecifiedMEDICARE ID NUMBER