Healthcare Provider Details

I. General information

NPI: 1205837366
Provider Name (Legal Business Name): SHAHAL ROZENBLATT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 KARL AVE STE 104
SMITHTOWN NY
11787-2744
US

IV. Provider business mailing address

50 KARL AVE STE 104
SMITHTOWN NY
11787-2744
US

V. Phone/Fax

Practice location:
  • Phone: 631-378-0741
  • Fax: 631-449-7970
Mailing address:
  • Phone: 631-378-0741
  • Fax: 631-449-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number016095
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number016095
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: