Healthcare Provider Details

I. General information

NPI: 1063774792
Provider Name (Legal Business Name): MRS. BOBBIE JO DEUEL-LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CLAYTON AVE
VESTAL NY
13850-2430
US

IV. Provider business mailing address

116 CLAYTON AVE
VESTAL NY
13850-2430
US

V. Phone/Fax

Practice location:
  • Phone: 607-754-1101
  • Fax:
Mailing address:
  • Phone: 607-754-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number095142
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: