Healthcare Provider Details

I. General information

NPI: 1245142694
Provider Name (Legal Business Name): MICHELLE POLVADORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 N GOVERNEOUR RD
WICHITA KS
67206-1156
US

IV. Provider business mailing address

30 SHADYBROOK DR
WELLINGTON KS
67152-4729
US

V. Phone/Fax

Practice location:
  • Phone: 316-973-3949
  • Fax:
Mailing address:
  • Phone: 620-705-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number5813682783
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: