=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992010193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TREY J POLESKY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2010
-----------------------------------------------------
Last Update Date | 09/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2910 HARRIS ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95503-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-840-5511
-----------------------------------------------------
Fax | 877-761-3132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2910 HARRIS ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95503-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-840-5511
-----------------------------------------------------
Fax | 877-761-3132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150012634
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11031
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149015330
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 66343
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------