Provider Demographics
NPI:1184854879
Name:POLACEK, MARIA (LPC)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:POLACEK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:RETHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:9200 WATSON RD
Mailing Address - Street 2:STE G101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-1528
Mailing Address - Country:US
Mailing Address - Phone:314-367-5500
Mailing Address - Fax:314-843-0552
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-1363
Practice Address - Country:US
Practice Address - Phone:636-583-1800
Practice Address - Fax:636-583-9836
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001011576101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional