Provider Demographics
NPI:1780710038
Name:DZUBA, J MICHAEL (MSW)
Entity type:Individual
Prefix:
First Name:J
Middle Name:MICHAEL
Last Name:DZUBA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W SEDGWICK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3442
Mailing Address - Country:US
Mailing Address - Phone:215-849-2747
Mailing Address - Fax:
Practice Address - Street 1:825 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1509
Practice Address - Country:US
Practice Address - Phone:302-655-7110
Practice Address - Fax:302-655-6185
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ1-0000120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker