Provider Demographics
NPI:1750982989
Name:POLUYANSKIS, KRISTEN (PSYD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:POLUYANSKIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14133 JASON CRANDALL DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-5353
Mailing Address - Country:US
Mailing Address - Phone:808-387-9412
Mailing Address - Fax:
Practice Address - Street 1:14133 JASON CRANDALL DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-5353
Practice Address - Country:US
Practice Address - Phone:808-387-9412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020031502103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750982989OtherNPI NUMBER