Provider Demographics
NPI:1689390189
Name:HASBROUCK, ROLAND GARDNER
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:GARDNER
Last Name:HASBROUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3312
Mailing Address - Country:US
Mailing Address - Phone:845-486-2950
Mailing Address - Fax:
Practice Address - Street 1:412 MAIN ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3312
Practice Address - Country:US
Practice Address - Phone:845-486-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)