Provider Demographics
NPI:1588152482
Name:POLCYN, KIMBERLY ANNE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:POLCYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9671
Mailing Address - Country:US
Mailing Address - Phone:231-392-2381
Mailing Address - Fax:
Practice Address - Street 1:1987 BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9671
Practice Address - Country:US
Practice Address - Phone:231-392-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8466632Medicaid