Provider Demographics
NPI:1881284784
Name:BOMBARD, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BOMBARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-448-3587
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD STE 1F
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3808
Practice Address - Country:US
Practice Address - Phone:315-458-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1105091041C0700X, 104100000X
NY106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist