Provider Demographics
NPI:1982255592
Name:POLANIN, TAMELA STACY
Entity Type:Individual
Prefix:
First Name:TAMELA
Middle Name:STACY
Last Name:POLANIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2339 N 2000 ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ELMO
Mailing Address - State:IL
Mailing Address - Zip Code:62458-4175
Mailing Address - Country:US
Mailing Address - Phone:618-292-7373
Mailing Address - Fax:
Practice Address - Street 1:1703 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-3117
Practice Address - Country:US
Practice Address - Phone:618-283-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012372101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health