Provider Demographics
NPI:1649512112
Name:STALEY, BOBBY L (LCSW)
Entity type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:L
Last Name:STALEY
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 1:19825 DUNTON AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1409
Mailing Address - Country:US
Mailing Address - Phone:917-680-0082
Mailing Address - Fax:
Practice Address - Street 1:19605 FOOTHILL AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1413
Practice Address - Country:US
Practice Address - Phone:917-680-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23692101YA0400X
NY0835651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)