Provider Demographics
NPI:1912069154
Name:POLOGE, BENNETT (PHD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:POLOGE
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 1:5900 ARLINGTON AVE APT 7A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1313
Mailing Address - Country:US
Mailing Address - Phone:917-513-7196
Mailing Address - Fax:347-202-7166
Practice Address - Street 1:5900 ARLINGTON AVE APT 7A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1313
Practice Address - Country:US
Practice Address - Phone:917-513-7196
Practice Address - Fax:347-202-7166
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10065-1103T00000X, 103TC2200X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic