Provider Demographics
NPI:1598978561
Name:LEIBOWITZ, SUSAN (EDD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LEIBOWITZ
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 GARDNER ST
Mailing Address - Street 2:APT. 2 - 3
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-3805
Mailing Address - Country:US
Mailing Address - Phone:781-648-5226
Mailing Address - Fax:
Practice Address - Street 1:173 CHELSEA ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-4632
Practice Address - Country:US
Practice Address - Phone:781-388-6234
Practice Address - Fax:617-387-9768
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8178103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51255Medicare ID - Type Unspecified