Provider Demographics
NPI:1811067408
Name:POLCASTER, CHARLES R (PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:POLCASTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12804 S SENECA RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2169
Mailing Address - Country:US
Mailing Address - Phone:708-448-0884
Mailing Address - Fax:708-448-0594
Practice Address - Street 1:7804 W COLLEGE DR
Practice Address - Street 2:2NE
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1025
Practice Address - Country:US
Practice Address - Phone:708-448-0884
Practice Address - Fax:708-448-0594
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000331101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632157OtherBLUE CROSS BLUE SHIELD