Provider Demographics
NPI:1548735814
Name:LIEBES, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:LIEBES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N HWY 89 STE C
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2824
Mailing Address - Country:US
Mailing Address - Phone:801-393-6232
Mailing Address - Fax:801-393-4081
Practice Address - Street 1:19 W CENTER ST STE 201
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5803
Practice Address - Country:US
Practice Address - Phone:801-393-6232
Practice Address - Fax:801-393-4081
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT689175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist