Provider Demographics
NPI:1962971762
Name:CARDOM, ROBERT DAVID (LP, PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:CARDOM
Suffix:
Gender:M
Credentials:LP, PHD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:DAVID
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33 WOODLAKE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-4057
Mailing Address - Country:US
Mailing Address - Phone:859-421-9907
Mailing Address - Fax:
Practice Address - Street 1:33 WOODLAKE RD STE 104
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-4057
Practice Address - Country:US
Practice Address - Phone:859-421-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022846103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist