Provider Demographics
NPI:1699790030
Name:POLANSKY, JOAN MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:MARIE
Last Name:POLANSKY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 E MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-5211
Mailing Address - Country:US
Mailing Address - Phone:602-621-0468
Mailing Address - Fax:602-443-0401
Practice Address - Street 1:11110 N TATUM BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1607
Practice Address - Country:US
Practice Address - Phone:602-621-0468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3399103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ108196Medicare ID - Type Unspecified