MEDICARE: CHRYSTAL DAWN LIEBOLD-JOHNSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	77002	CA

General Provider Information

NPI Number	:	1578092979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRYSTAL DAWN LIEBOLD-JOHNSON LCSW

Provider Business Mailing Address
First Line	:	4529 SAINT DAVIDS ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-1216
Country	:	US
Telephone Number	:	646-957-4294
Fax Number	:

Provider Business Practice Location Address
First Line	:	4529 SAINT DAVIDS ST UNIT 101
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-1216
Country	:	US
Telephone Number	:	646-957-4294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	02/12/2026

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