Healthcare Provider Details

I. General information

NPI: 1538996830
Provider Name (Legal Business Name): SAMUEL MARK BROTKIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 WESTGATE DR STE 900
DURHAM NC
27707-2534
US

IV. Provider business mailing address

3500 WESTGATE DR STE 900
DURHAM NC
27707-2534
US

V. Phone/Fax

Practice location:
  • Phone: 516-880-4536
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008519
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: