Provider Demographics
NPI:1790988970
Name:ROLL, DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:ROLL
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 1:237 12TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579
Mailing Address - Country:US
Mailing Address - Phone:516-236-1553
Mailing Address - Fax:516-671-5790
Practice Address - Street 1:1025 NORTHERN BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1506
Practice Address - Country:US
Practice Address - Phone:516-236-1553
Practice Address - Fax:516-671-5790
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6414103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV8A711Medicare ID - Type UnspecifiedPSYCHOLOGIST