Provider Demographics
NPI:1083356489
Name:BOBBI PETRANCHUK
Entity type:Organization
Organization Name:BOBBI PETRANCHUK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRANCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-772-2151
Mailing Address - Street 1:11050 MT BELVEDERE BLVD RM 1113
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-2603
Mailing Address - Country:US
Mailing Address - Phone:315-772-2151
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD RM 1113
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-2603
Practice Address - Country:US
Practice Address - Phone:315-772-2151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354316Medicaid