Provider Demographics
NPI:1912345505
Name:POLLEY, THOMAS A (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:POLLEY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 DRAHAM RD NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3828
Mailing Address - Country:US
Mailing Address - Phone:360-951-8120
Mailing Address - Fax:
Practice Address - Street 1:1941 DRAHAM RD NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3828
Practice Address - Country:US
Practice Address - Phone:360-951-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003586171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOT00003586OtherWASHINGTON STATE DEPARTMENT OF HEALTH