Provider Demographics
NPI:1003286972
Name:POLK, CHADDRICK (PT, OTA)
Entity Type:Individual
Prefix:
First Name:CHADDRICK
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:PT, OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 E UNIVERSITY DR STE 30-165
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-9152
Mailing Address - Country:US
Mailing Address - Phone:972-347-9454
Mailing Address - Fax:972-499-2527
Practice Address - Street 1:4261 E UNIVERSITY DR STE 30-165
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078
Practice Address - Country:US
Practice Address - Phone:972-347-9604
Practice Address - Fax:972-499-2527
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-04
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1309289225100000X
TX213531224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant