Provider Demographics
NPI:1164728127
Name:LEEBOLD, BOBBY JOE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:JOE
Last Name:LEEBOLD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0604
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6071
Practice Address - Country:US
Practice Address - Phone:309-310-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0132701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical