Healthcare Provider Details

I. General information

NPI: 1215050737
Provider Name (Legal Business Name): ELLEN SUE POLAN MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 GRAND AVE
GRAND JUNCTION CO
81501-2738
US

IV. Provider business mailing address

802 OURAY AVE
GRAND JUNCTION CO
81501-3328
US

V. Phone/Fax

Practice location:
  • Phone: 970-270-4005
  • Fax:
Mailing address:
  • Phone: 970-243-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC 46
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: