Provider Demographics
NPI:1932784071
Name:POLYAK, DANIEL (LP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:POLYAK
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 GREENE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-1109
Mailing Address - Country:US
Mailing Address - Phone:914-671-9974
Mailing Address - Fax:
Practice Address - Street 1:488 GREENE AVE APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-1109
Practice Address - Country:US
Practice Address - Phone:914-671-9974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001093102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty