Provider Demographics
NPI:1437296365
Name:VAN RENSBURG, POLLY WHITMAN (PH D)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:WHITMAN
Last Name:VAN RENSBURG
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 E VALLEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-6768
Mailing Address - Country:US
Mailing Address - Phone:480-484-5077
Mailing Address - Fax:480-484-5106
Practice Address - Street 1:8505 E VALLEY VIEW RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-6768
Practice Address - Country:US
Practice Address - Phone:480-484-5077
Practice Address - Fax:480-484-5106
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ626129Medicaid