Healthcare Provider Details

I. General information

NPI: 1972791358
Provider Name (Legal Business Name): MATTHEW TODD LEIBSOHN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 114TH AVE SE STE 100
BELLEVUE WA
98004-6962
US

IV. Provider business mailing address

3206 74TH PL SE
MERCER ISLAND WA
98040-3400
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-7722
  • Fax: 425-320-1021
Mailing address:
  • Phone: 425-453-7722
  • Fax: 425-320-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1764
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: