Provider Demographics
NPI:1437237443
Name:POLAKOFF, MARSHALL (PSYD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:POLAKOFF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2102
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350
Mailing Address - Country:US
Mailing Address - Phone:815-434-0806
Mailing Address - Fax:815-434-0806
Practice Address - Street 1:2590 COVEL BLUFF RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-9260
Practice Address - Country:US
Practice Address - Phone:815-434-0806
Practice Address - Fax:815-434-0806
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL754800Medicare ID - Type Unspecified