Provider Demographics
NPI:1093393621
Name:BIBBS, LEROY JR (MASTER'S DEGREE HUMA)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:BIBBS
Suffix:JR
Gender:M
Credentials:MASTER'S DEGREE HUMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LONG RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9284
Mailing Address - Country:US
Mailing Address - Phone:215-266-8158
Mailing Address - Fax:
Practice Address - Street 1:203 LONG RIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-9284
Practice Address - Country:US
Practice Address - Phone:215-266-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA27-0843094320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities