Provider Demographics
NPI:1295719953
Name:RENDERER, BOBBI L (PHD)
Entity type:Individual
Prefix:DR
First Name:BOBBI
Middle Name:L
Last Name:RENDERER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 SPRINGFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:UPPER JAY
Mailing Address - State:NY
Mailing Address - Zip Code:12987
Mailing Address - Country:US
Mailing Address - Phone:518-946-7487
Mailing Address - Fax:
Practice Address - Street 1:48 SPRINGFIELD RD
Practice Address - Street 2:
Practice Address - City:UPPER JAY
Practice Address - State:NY
Practice Address - Zip Code:12987-3204
Practice Address - Country:US
Practice Address - Phone:518-586-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012414103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02430459Medicaid
NY02430459Medicaid
P92849Medicare UPIN