Provider Demographics
NPI:1750481495
Name:TRAVAGLIONE, LEONARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:TRAVAGLIONE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WASHINGTON AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-7303
Mailing Address - Country:US
Mailing Address - Phone:518-392-7314
Mailing Address - Fax:518-862-2175
Practice Address - Street 1:300 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-7303
Practice Address - Country:US
Practice Address - Phone:518-392-7314
Practice Address - Fax:518-862-2175
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011531103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011531OtherLICENSE
NY01416760Medicaid
NY134284OtherVALUE OPTIONS
NY01905259Medicaid
NYV94321Medicare ID - Type UnspecifiedDOWNSTATE LEN
NY56279AMedicare ID - Type UnspecifiedPRACTICE UPSTATE
NY01416760Medicaid
NYV0W561Medicare UPIN