Provider Demographics
NPI:1477867315
Name:LEIBOVITZ, DAVID
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:LEIBOVITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 CHAPEL AVE W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-2051
Mailing Address - Country:US
Mailing Address - Phone:856-482-9000
Mailing Address - Fax:856-482-1159
Practice Address - Street 1:2250 CHAPEL AVE W
Practice Address - Street 2:SUITE 100
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2051
Practice Address - Country:US
Practice Address - Phone:856-482-9000
Practice Address - Fax:856-482-1159
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00479300103TC0700X
DEB1-0000837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0244627Medicaid
NJ800566AOYMedicare PIN