Healthcare Provider Details

I. General information

NPI: 1295309987
Provider Name (Legal Business Name): SPENCER W LIEBEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S KOMAS DR STE 106A
SALT LAKE CITY UT
84108-1225
US

IV. Provider business mailing address

2979 VERLE AVE
ANN ARBOR MI
48108-1870
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-9350
  • Fax:
Mailing address:
  • Phone: 208-881-8216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7615273-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: