Healthcare Provider Details

I. General information

NPI: 1033221338
Provider Name (Legal Business Name): MATTHEW BRUCE POLLACK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 EAST MAIN STREET SUITE 214
PATCHOGUE NY
11772
US

IV. Provider business mailing address

475 EAST MAIN STREET SUITE 214
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-8507
  • Fax: 631-654-8507
Mailing address:
  • Phone: 631-654-8507
  • Fax: 631-654-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0090071
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier014738859
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: