Provider Demographics
NPI:1639884885
Name:LEBRON, WANDA IVETTE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:IVETTE
Last Name:LEBRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-6007
Mailing Address - Country:US
Mailing Address - Phone:570-520-8357
Mailing Address - Fax:
Practice Address - Street 1:2324 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-6007
Practice Address - Country:US
Practice Address - Phone:570-520-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities