Provider Demographics
NPI:1275600306
Name:POLSTER, BRENDA KAY (BS, OT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:POLSTER
Suffix:
Gender:F
Credentials:BS, OT
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KAY
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, OT
Mailing Address - Street 1:744 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3603
Mailing Address - Country:US
Mailing Address - Phone:812-855-8436
Mailing Address - Fax:812-855-1683
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002137A156F00000X, 225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200854470Medicaid
IN000000584866OtherANTHEM
IN000000584866OtherANTHEM