Provider Demographics
NPI:1013596790
Name:POLACHEK, ASHTON (OTR)
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:
Last Name:POLACHEK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3293 N 1750 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-4938
Mailing Address - Country:US
Mailing Address - Phone:214-300-9960
Mailing Address - Fax:
Practice Address - Street 1:365 W 1550 N STE H
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2279
Practice Address - Country:US
Practice Address - Phone:801-618-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121714225X00000X
UT12652430-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist