Healthcare Provider Details

I. General information

NPI: 1164443800
Provider Name (Legal Business Name): LEO J D'ANNIBALLE JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 VENETIAN CT
NAPLES FL
34109
US

IV. Provider business mailing address

6360 TECHSTER BLVD STE 1
FORT MYERS FL
33966-4805
US

V. Phone/Fax

Practice location:
  • Phone: 239-236-5448
  • Fax:
Mailing address:
  • Phone: 239-223-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002831A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8499
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: