Provider Demographics
NPI:1336260249
Name:TUMBARELLO, ROGER J
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
Last Name:TUMBARELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:J
Other - Last Name:TUMBARELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-0719
Mailing Address - Country:US
Mailing Address - Phone:845-229-6585
Mailing Address - Fax:
Practice Address - Street 1:4232 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538-1766
Practice Address - Country:US
Practice Address - Phone:845-229-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6118103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV21311Medicare ID - Type Unspecified