Provider Demographics
NPI:1790325496
Name:FARRELL, FRANK (PHD)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:
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 1:105 LEEWARD LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2307
Mailing Address - Country:US
Mailing Address - Phone:631-901-7777
Mailing Address - Fax:631-395-3207
Practice Address - Street 1:646 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2235
Practice Address - Country:US
Practice Address - Phone:631-901-7777
Practice Address - Fax:631-395-3207
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017980-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
14506259OtherCAQH ID#