Provider Demographics
NPI:1083095434
Name:POLTORAK, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:POLTORAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANIA
Other - Middle Name:
Other - Last Name:POLTORAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:40 AVON MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3753
Mailing Address - Country:US
Mailing Address - Phone:860-325-0305
Mailing Address - Fax:
Practice Address - Street 1:40 AVON MEADOW LN BLDG 40
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3753
Practice Address - Country:US
Practice Address - Phone:860-325-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT3124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health