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General NPI Number Information
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NPI Number | 1639125446
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Entity Type | Individual
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Provider Name | JONATHAN LEBOLT PHD, LCSW, CGP
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Gender | Male
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Dates
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Enumeration Date | 05/25/2006
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Last Update Date | 12/14/2022
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Provider Practice Location Address
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Address Line | 38 CERONE CT
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City | WEST ORANGE
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State | NJ
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Zip | 07052-4113
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Country | US
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Telephone | 973-524-4917
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Fax |
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Provider Business Mailing Address
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Address Line | 38 CERONE CT
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City | WEST ORANGE
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State | NJ
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Zip | 07052-4113
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Country | US
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Telephone | 973-524-4917
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 20618
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License Number State | MD
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