Provider Demographics
NPI:1740901529
Name:BOBB-MITCHELL, LEIBA
Entity type:Individual
Prefix:
First Name:LEIBA
Middle Name:
Last Name:BOBB-MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LEIBA
Other - Middle Name:
Other - Last Name:BOBB-MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 FRANKLIN ST STE 204
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2107
Practice Address - Country:US
Practice Address - Phone:518-372-7031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0000000Medicaid
NY01420800Medicaid