Healthcare Provider Details

I. General information

NPI: 1356385926
Provider Name (Legal Business Name): ELLEN L POLESHUCK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/05/2023
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0002
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 668
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2691
  • Fax: 585-242-8707
Mailing address:
  • Phone: 585-275-2691
  • Fax: 585-242-8707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number014029
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number14029
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number014029
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number014029
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: