Healthcare Provider Details

I. General information

NPI: 1184922056
Provider Name (Legal Business Name): ROBERT B DEVINNEY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MEDFORD AVE
PATCHOGUE NY
11772-1223
US

IV. Provider business mailing address

414 SUNRISE HWY PMB 329
PATCHOGUE NY
11772-2254
US

V. Phone/Fax

Practice location:
  • Phone: 631-987-3780
  • Fax: 631-204-0069
Mailing address:
  • Phone: 631-987-3780
  • Fax: 631-204-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number012661-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: