Provider Demographics
NPI:1669487229
Name:POLUSNY, MELISSA ANDERSON (PHD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANDERSON
Last Name:POLUSNY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VETERANS DR
Mailing Address - Street 2:116B
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2309
Mailing Address - Country:US
Mailing Address - Phone:612-725-2125
Mailing Address - Fax:612-727-5633
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:116B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-725-2125
Practice Address - Fax:612-727-5633
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4362103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical