Provider Demographics
NPI:1497520399
Name:POLACZEK, DREW
Entity type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:POLACZEK
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 1:1616 GROVE COURT
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4799
Mailing Address - Country:US
Mailing Address - Phone:779-875-1357
Mailing Address - Fax:
Practice Address - Street 1:44 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4402
Practice Address - Country:US
Practice Address - Phone:855-528-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2024-10-17
Deactivation Date:2024-09-10
Deactivation Code:
Reactivation Date:2024-10-02
Provider Licenses
StateLicense IDTaxonomies
IL1-24-75575103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst