Provider Demographics
NPI:1902604895
Name:POLYCHRONIS, ELENA DIANE
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:DIANE
Last Name:POLYCHRONIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 PHEASANT WAY
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5533
Mailing Address - Country:US
Mailing Address - Phone:385-232-6253
Mailing Address - Fax:
Practice Address - Street 1:1315 PHEASANT WAY
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5533
Practice Address - Country:US
Practice Address - Phone:385-232-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB1177864106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician