Healthcare Provider Details

I. General information

NPI: 1881284784
Provider Name (Legal Business Name): LEAH BOMBARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD STE 1F
LIVERPOOL NY
13088-3808
US

IV. Provider business mailing address

5100 W TAFT RD
LIVERPOOL NY
13088-3807
US

V. Phone/Fax

Practice location:
  • Phone: 315-458-6111
  • Fax:
Mailing address:
  • Phone: 315-448-3587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number110509
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110509
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: