MEDICARE: DR. JOAN MARIE POLANSKY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	3399	AZ

General Provider Information

NPI Number	:	1699790030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOAN MARIE POLANSKY PH.D.

Provider Business Mailing Address
First Line	:	4641 E MOUNTAIN VIEW RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-5211
Country	:	US
Telephone Number	:	602-621-0468
Fax Number	:	602-443-0401

Provider Business Practice Location Address
First Line	:	11110 N TATUM BLVD
Second Line	:	SUITE 103
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1607
Country	:	US
Telephone Number	:	602-621-0468
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/08/2007

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