=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609961366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELDON S LIBBY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 04/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 385 TERHUNE AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-7915
-----------------------------------------------------
Fax | 973-777-2226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 385 TERHUNE AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-7915
-----------------------------------------------------
Fax | 973-777-2226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 035020-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC01432900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------