Provider Demographics
NPI:1528411956
Name:POLYAK, MARINA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:POLYAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5-11 EUGENE ST
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5-11 EUGENE ST
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4055
Practice Address - Country:US
Practice Address - Phone:646-752-3487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07945225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist