Healthcare Provider Details

I. General information

NPI: 1619800745
Provider Name (Legal Business Name): DR. ILANA RACHEL POLAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 BROOKLAWN AVE
BRIDGEPORT CT
06604-2012
US

IV. Provider business mailing address

180 BROOKLAWN AVE
BRIDGEPORT CT
06604-2012
US

V. Phone/Fax

Practice location:
  • Phone: 203-274-0218
  • Fax:
Mailing address:
  • Phone: 203-274-0218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number011737
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: