Provider Demographics
NPI:1790419323
Name:POLLACK, KARLISSA
Entity Type:Individual
Prefix:
First Name:KARLISSA
Middle Name:
Last Name:POLLACK
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 1:11605 DESTINATION DR APT 5305
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-4791
Mailing Address - Country:US
Mailing Address - Phone:270-872-3790
Mailing Address - Fax:
Practice Address - Street 1:11605 DESTINATION DR APT 5305
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-4791
Practice Address - Country:US
Practice Address - Phone:270-872-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000721615103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool