Healthcare Provider Details

I. General information

NPI: 1609824960
Provider Name (Legal Business Name): BOBBI PETRANCHUK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/31/2024
Certification Date:
Deactivation Date: 09/25/2024
Reactivation Date: 10/31/2024

III. Provider practice location address

7550 S STATE ST
LOWVILLE NY
13367-1533
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601-0091
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-5450
  • Fax: 315-785-8628
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: