Provider Demographics
NPI:1700939519
Name:POLTORAK, DUNYA TERESA YALDOO (PHD)
Entity Type:Individual
Prefix:DR
First Name:DUNYA
Middle Name:TERESA YALDOO
Last Name:POLTORAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W BROWN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6022
Mailing Address - Country:US
Mailing Address - Phone:248-203-2333
Mailing Address - Fax:248-203-2444
Practice Address - Street 1:199 W BROWN ST
Practice Address - Street 2:STE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6022
Practice Address - Country:US
Practice Address - Phone:248-203-2333
Practice Address - Fax:248-203-2444
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5673103T00000X
MI6301014136103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2221910Medicaid
OHP08368Medicare UPIN
OH2221910Medicaid