Provider Demographics
NPI:1487029302
Name:POLAN, PAMELA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:POLAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12010 CALDWALLER RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8418
Mailing Address - Country:US
Mailing Address - Phone:810-629-8876
Mailing Address - Fax:
Practice Address - Street 1:12319 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2946
Practice Address - Country:US
Practice Address - Phone:810-991-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000843235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist