Provider Demographics
NPI:1861626442
Name:POLTROCK, SCOTT LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LEE
Last Name:POLTROCK
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 1:1812 HADDONFIELD BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-3736
Mailing Address - Country:US
Mailing Address - Phone:732-535-3481
Mailing Address - Fax:732-587-0713
Practice Address - Street 1:1812 HADDONFIELD BERLIN RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-3736
Practice Address - Country:US
Practice Address - Phone:732-535-3481
Practice Address - Fax:732-587-0713
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00466500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical