Provider Demographics
NPI:1619075876
Name:LEEBERG, ELIZABETH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:LEEBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 SE DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1333
Mailing Address - Country:US
Mailing Address - Phone:541-318-7023
Mailing Address - Fax:541-318-0252
Practice Address - Street 1:223 SE DAVIS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1333
Practice Address - Country:US
Practice Address - Phone:541-318-7023
Practice Address - Fax:541-318-0252
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR106970Medicare PIN