Healthcare Provider Details

I. General information

NPI: 1629450408
Provider Name (Legal Business Name): MICHAEL KOBLENSKY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 W MAIN ST
EPHRATA PA
17522-1103
US

IV. Provider business mailing address

41 AUTUMN BLAZE WAY
EPHRATA PA
17522-2730
US

V. Phone/Fax

Practice location:
  • Phone: 717-288-7638
  • Fax:
Mailing address:
  • Phone: 610-350-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025602
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: