Provider Demographics
NPI:1932114691
Name:RADDOCK, FRANKLIN (PHD)
Entity Type:Individual
Prefix:
First Name:FRANKLIN
Middle Name:
Last Name:RADDOCK
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 1:125 TURNER RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3604
Mailing Address - Country:US
Mailing Address - Phone:203-253-7883
Mailing Address - Fax:
Practice Address - Street 1:1745 BROADWAY
Practice Address - Street 2:17 FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4640
Practice Address - Country:US
Practice Address - Phone:212-851-8100
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00588514Medicaid
NYV1704Medicare PIN