Provider Demographics
NPI:1588999460
Name:LEBOEUF, DESIREE A (PHD)
Entity type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:A
Last Name:LEBOEUF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DESIREE
Other - Middle Name:A
Other - Last Name:LEBOEUF-DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DESIREE KROLL
Mailing Address - Street 1:74 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1026
Mailing Address - Country:US
Mailing Address - Phone:315-261-9210
Mailing Address - Fax:
Practice Address - Street 1:74 STATE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1026
Practice Address - Country:US
Practice Address - Phone:315-261-9210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X, 103TF0200X, 103TM1800X, 103TP2701X
NY022976-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022976OtherLICENSE/CERTIFICATION #
NY022976OtherLICENSE/CERTIFICATION #