Basic Information
| Provider Information | |||||||||
| NPI: | 1669817607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIBOW | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STUART | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD, DRPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 954 W FOOTHILL BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917863782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099464222 | ||||||||
| FaxNumber: | 9099468243 | ||||||||
| Practice Location | |||||||||
| Address1: | 954 W FOOTHILL BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917863782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099464222 | ||||||||
| FaxNumber: | 9099468243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2013 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 05438 | MD | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY31070 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.