Provider Demographics
NPI:1558576678
Name:POLAN, INDIRA ANN (OT)
Entity Type:Individual
Prefix:
First Name:INDIRA ANN
Middle Name:
Last Name:POLAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 CENTRAL PARK DR APT 2432
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3526
Mailing Address - Country:US
Mailing Address - Phone:530-913-6851
Mailing Address - Fax:
Practice Address - Street 1:9089 CLAIREMONT MESA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1225
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT8593225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157462721Medicaid