Provider Demographics
NPI:1548482532
Name:TARTAKOFF, RAYMOND REUBEN
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:REUBEN
Last Name:TARTAKOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 CONTINENTAL RD
Mailing Address - Street 2:
Mailing Address - City:NAPANOCH
Mailing Address - State:NY
Mailing Address - Zip Code:12458
Mailing Address - Country:US
Mailing Address - Phone:845-647-2112
Mailing Address - Fax:
Practice Address - Street 1:216 CONTINENTAL RD
Practice Address - Street 2:
Practice Address - City:NAPANOCH
Practice Address - State:NY
Practice Address - Zip Code:12458
Practice Address - Country:US
Practice Address - Phone:845-647-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053380-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1280347OtherCIGNA ID
NY01727242Medicaid
NY1014020OtherBEACON HEALTH ID
NY157412000OtherMAGELLAN ID
NYP2083481OtherOXFORD ID