Provider Demographics
NPI:1538305271
Name:POLANCO, SARA TERESA (OTR/L, DSC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:TERESA
Last Name:POLANCO
Suffix:
Gender:F
Credentials:OTR/L, DSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 BIG SKY DR
Mailing Address - Street 2:APT E-304
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5273
Mailing Address - Country:US
Mailing Address - Phone:719-602-9441
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:OCCUPATIONAL THERAPY DEPARTMENT
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:719-602-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004542225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist