Provider Demographics
NPI:1992010193
Name:POLESKY, TREY J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TREY
Middle Name:J
Last Name:POLESKY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4811
Mailing Address - Country:US
Mailing Address - Phone:707-840-5511
Mailing Address - Fax:877-761-3132
Practice Address - Street 1:2910 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4811
Practice Address - Country:US
Practice Address - Phone:707-840-5511
Practice Address - Fax:877-761-3132
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150012634104100000X
SC110311041C0700X
IL1490153301041C0700X
CA663431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300162574Medicare PIN