Provider Demographics
NPI:1083497895
Name:POLIVKA, KELLY ANN (DPT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:POLIVKA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6552 ROYAL VALLEY CV
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-6120
Mailing Address - Country:US
Mailing Address - Phone:630-991-7061
Mailing Address - Fax:
Practice Address - Street 1:2868 SUMMER OAKS DR STE 104
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-2818
Practice Address - Country:US
Practice Address - Phone:901-907-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist