Provider Demographics
NPI:1457781452
Name:POLACEK, DEBRA I (LMFT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:I
Last Name:POLACEK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DEB
Other - Middle Name:
Other - Last Name:POLACEK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:5930 SEMINOLE CENTRE CT STE A
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5165
Mailing Address - Country:US
Mailing Address - Phone:608-571-7470
Mailing Address - Fax:
Practice Address - Street 1:5930 SEMINOLE CENTRE CT STE A
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5165
Practice Address - Country:US
Practice Address - Phone:608-571-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1111-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist