Provider Demographics
NPI:1679650329
Name:MANDELBAUM, LEAH LISA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:LISA
Last Name:MANDELBAUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 CENTRAL AVE APT 115
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2207
Mailing Address - Country:US
Mailing Address - Phone:516-569-5720
Mailing Address - Fax:
Practice Address - Street 1:2795 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5857
Practice Address - Country:US
Practice Address - Phone:718-761-9800
Practice Address - Fax:718-370-1142
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070497-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLGON365610Medicare ID - Type UnspecifiedMEDICARE NUMBER