Provider Demographics
NPI:1043323728
Name:BLEIWAS, RANDOLPH SR (LCSW)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:
Last Name:BLEIWAS
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:BLEIWAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:242 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5302
Mailing Address - Country:US
Mailing Address - Phone:845-354-9200
Mailing Address - Fax:845-354-8555
Practice Address - Street 1:242 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5302
Practice Address - Country:US
Practice Address - Phone:845-354-9200
Practice Address - Fax:845-354-8555
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0466781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN4B831Medicare ID - Type UnspecifiedMEDICARE