Basic Information
| Provider Information | |||||||||
| NPI: | 1215421474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIBMAN | ||||||||
| FirstName: | ILIYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8397 FOUNTAIN AVE APT 206 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900692936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139256210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD # 201 | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189850560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 06/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.