Provider Demographics
NPI:1609917608
Name:FARRELL, ROBERT ALFRED (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALFRED
Last Name:FARRELL
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 1:10 GRACE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2423
Mailing Address - Country:US
Mailing Address - Phone:516-829-5982
Mailing Address - Fax:
Practice Address - Street 1:10 GRACE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2423
Practice Address - Country:US
Practice Address - Phone:516-829-5982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010188103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350141Medicaid
NY01350141Medicaid
NY03024Medicare ID - Type UnspecifiedGHI
NYC66912Medicare UPIN