Provider Demographics
NPI:1104964410
Name:POLIN, ROBERT DAVID (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DAVID
Last Name:POLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 GNARLED HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-689-8862
Mailing Address - Fax:631-246-6492
Practice Address - Street 1:646 MAIN ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-689-8862
Practice Address - Fax:631-246-6492
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02330611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN32151Medicare ID - Type Unspecified