Provider Demographics
NPI:1184922056
Name:DEVINNEY, ROBERT B (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:DEVINNEY
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 1:414 SUNRISE HWY
Mailing Address - Street 2:PMB 329
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2254
Mailing Address - Country:US
Mailing Address - Phone:631-987-3780
Mailing Address - Fax:631-204-0069
Practice Address - Street 1:105 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1223
Practice Address - Country:US
Practice Address - Phone:631-987-3780
Practice Address - Fax:631-204-0069
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012661-1103TC0700X
103G00000X, 103TA0400X, 103TA0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation