Healthcare Provider Details

I. General information

NPI: 1760028575
Provider Name (Legal Business Name): LEIBOW PSYCHOLOGY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 10/04/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11175 CAMPUS ST
LOMA LINDA CA
92350-1700
US

IV. Provider business mailing address

8583 IRVINE CENTER DR # 381
IRVINE CA
92618-4298
US

V. Phone/Fax

Practice location:
  • Phone: 305-336-1168
  • Fax:
Mailing address:
  • Phone: 305-336-1168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL LEIBOW
Title or Position: PRESIDENT
Credential: PSYD
Phone: 305-336-1168