Provider Demographics
NPI:1356516652
Name:TROUTMAN, H. TAD (PHD)
Entity type:Individual
Prefix:DR
First Name:H.
Middle Name:TAD
Last Name:TROUTMAN
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 1:31 OAK ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2841
Mailing Address - Country:US
Mailing Address - Phone:631-598-9217
Mailing Address - Fax:866-586-3157
Practice Address - Street 1:31 OAK ST
Practice Address - Street 2:SUITE 21
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2841
Practice Address - Country:US
Practice Address - Phone:631-598-9217
Practice Address - Fax:866-586-3157
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02981244Medicaid
NY60054OtherAETNA
NY1089280OtherAFFINITY HEALTH PLAN
NY1089280OtherAFFINITY HEALTH PLAN