Provider Demographics
NPI:1851700041
Name:POLAK, MARY JOAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOAN
Last Name:POLAK
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 1:1700 BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-2418
Mailing Address - Country:US
Mailing Address - Phone:605-260-9284
Mailing Address - Fax:605-260-9284
Practice Address - Street 1:1700 BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-2418
Practice Address - Country:US
Practice Address - Phone:605-260-9284
Practice Address - Fax:605-260-9284
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC7157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498349901Medicaid