Provider Demographics
NPI:1972510295
Name:KLEBANOFF, LEWIS BERNARD (PHD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:BERNARD
Last Name:KLEBANOFF
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 1:32 SIMMONS POND RD W
Mailing Address - Street 2:
Mailing Address - City:DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02638-2541
Mailing Address - Country:US
Mailing Address - Phone:508-385-6813
Mailing Address - Fax:508-385-6813
Practice Address - Street 1:32 SIMMONS POND RD W
Practice Address - Street 2:
Practice Address - City:DENNIS
Practice Address - State:MA
Practice Address - Zip Code:02638-2541
Practice Address - Country:US
Practice Address - Phone:508-385-6813
Practice Address - Fax:508-385-6813
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW01777OtherBCBS
MAW51296Medicare ID - Type Unspecified