Healthcare Provider Details

I. General information

NPI: 1700148509
Provider Name (Legal Business Name): SUSAN RUTH LEIBOLD RN, MSSN, CNS-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 WELBORN ST 4TH FLOOR
DALLAS TX
75219-3924
US

IV. Provider business mailing address

2222 WELBORN ST 4TH FLOOR
DALLAS TX
75219-3924
US

V. Phone/Fax

Practice location:
  • Phone: 214-559-7860
  • Fax: 214-559-7835
Mailing address:
  • Phone: 214-559-7860
  • Fax: 214-559-7835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number624693
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: