Provider Demographics
NPI:1033317466
Name:POLACHECK, MATTHEW SETH (PSY-D)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SETH
Last Name:POLACHECK
Suffix:
Gender:M
Credentials:PSY-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1143 SIERRA ALTA WAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069
Mailing Address - Country:US
Mailing Address - Phone:562-225-4093
Mailing Address - Fax:815-717-7625
Practice Address - Street 1:9911 W. PICO BLVD.
Practice Address - Street 2:STE. 1480
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035
Practice Address - Country:US
Practice Address - Phone:562-225-4093
Practice Address - Fax:815-717-7625
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22442103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL932AMedicare UPIN