Provider Demographics
NPI:1033221338
Name:POLLACK, MATTHEW BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRUCE
Last Name:POLLACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 EAST MAIN STREET
Mailing Address - Street 2:SUITE 214
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-654-8507
Mailing Address - Fax:631-654-8507
Practice Address - Street 1:475 EAST MAIN STREET
Practice Address - Street 2:SUITE 214
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-654-8507
Practice Address - Fax:631-654-8507
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0090071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014738859Medicaid
NYV29312Medicare ID - Type Unspecified