Provider Demographics
NPI:1891757134
Name:POLLOCK, KENNETH M (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:POLLOCK
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 1:22 SAW MILL RIVER RD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-1533
Mailing Address - Country:US
Mailing Address - Phone:914-593-1729
Mailing Address - Fax:914-593-1790
Practice Address - Street 1:VASSAR BROTHERS HOSPITAL
Practice Address - Street 2:45 READE PL
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601
Practice Address - Country:US
Practice Address - Phone:914-493-7124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004505103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01984207Medicaid
NYV63951Medicare PIN