Provider Demographics
NPI:1013329333
Name:POLAK, KATHLEEN (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:POLAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 BELLE TERRE RD
Mailing Address - Street 2:STE 204
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1977
Mailing Address - Country:US
Mailing Address - Phone:631-474-0008
Mailing Address - Fax:631-474-0224
Practice Address - Street 1:635 BELLE TERRE RD
Practice Address - Street 2:STE 204
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1977
Practice Address - Country:US
Practice Address - Phone:631-474-0008
Practice Address - Fax:631-474-0224
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037194174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist