Provider Demographics
NPI:1629634662
Name:POLANSKY, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:POLANSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5602 PRESIDIO PKWY APT 2213
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3097
Mailing Address - Country:US
Mailing Address - Phone:361-834-3003
Mailing Address - Fax:
Practice Address - Street 1:12758 CIMARRON PATH STE 127
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3498
Practice Address - Country:US
Practice Address - Phone:855-374-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX7856103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician