Provider Demographics
NPI:1669817607
Name:LEIBOW, MICHAEL STUART (PSYD, DRPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STUART
Last Name:LEIBOW
Suffix:
Gender:M
Credentials:PSYD, DRPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 W FOOTHILL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3782
Mailing Address - Country:US
Mailing Address - Phone:909-946-4222
Mailing Address - Fax:909-946-8243
Practice Address - Street 1:954 W FOOTHILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3782
Practice Address - Country:US
Practice Address - Phone:909-946-4222
Practice Address - Fax:909-946-8243
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05438103TC0700X
CAPSY31070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical