Provider Demographics
NPI:1093422834
Name:POLASEK, MISTY (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:POLASEK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:MISTY
Other - Middle Name:
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:403 MACARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-3124
Mailing Address - Country:US
Mailing Address - Phone:361-655-7398
Mailing Address - Fax:
Practice Address - Street 1:403 MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-3124
Practice Address - Country:US
Practice Address - Phone:361-655-7398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty