1134104151 NPI number — MS. ELIZABETH P POLANKA LPCC IMFT

Table of content: MS. ELIZABETH P POLANKA LPCC IMFT (NPI 1134104151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134104151 NPI number — MS. ELIZABETH P POLANKA LPCC IMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLANKA
Provider First Name:
ELIZABETH
Provider Middle Name:
P
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPCC IMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134104151
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 N LOCUST ST
Provider Second Line Business Mailing Address:
SUITE B 3
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45056-1192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-523-8991
Provider Business Mailing Address Fax Number:
513-523-8991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 N LOCUST ST
Provider Second Line Business Practice Location Address:
SUITE B 3
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45056-1192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-523-8991
Provider Business Practice Location Address Fax Number:
513-523-8991
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  E1045 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: E0007 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 255395 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 429908685003 . This is a "MEDICAL MUTUAL" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 6268092 . This is a "UNITED BEHAVIOREL HEALTH" identifier . This identifiers is of the category "OTHER".




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