Provider Demographics
NPI:1710614078
Name:LEIBOVICH, HARRY AXEL JR (BC-HIS)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:AXEL
Last Name:LEIBOVICH
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4828
Mailing Address - Country:US
Mailing Address - Phone:801-266-3751
Mailing Address - Fax:
Practice Address - Street 1:5261 S STATE ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4828
Practice Address - Country:US
Practice Address - Phone:801-266-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT85666164601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist