1790745693 NPI number — MS. JEANNA SUZANNE POLONCHEK ED.D, ATC, CPED, OT-

Table of content: MS. JEANNA SUZANNE POLONCHEK ED.D, ATC, CPED, OT- (NPI 1790745693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790745693 NPI number — MS. JEANNA SUZANNE POLONCHEK ED.D, ATC, CPED, OT-

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLONCHEK
Provider First Name:
JEANNA
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ED.D, ATC, CPED, OT-
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:
1790745693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 CRANE AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAUNTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02780-7232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-295-5100
Provider Business Mailing Address Fax Number:
508-295-9467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 RECOVERY RD
Provider Second Line Business Practice Location Address:
SUITE FOUR
Provider Business Practice Location Address City Name:
WAREHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02571-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-295-8800
Provider Business Practice Location Address Fax Number:
508-295-9467
Provider Enumeration Date:
03/24/2006

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: 174400000X , with the licence number:  248 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5788400001 . This is a "PTAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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