Provider Demographics
NPI:1871570119
Name:POLASEK, KIM A (PT)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:POLASEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:TAFT
Mailing Address - State:TX
Mailing Address - Zip Code:78390-2706
Mailing Address - Country:US
Mailing Address - Phone:361-528-3018
Mailing Address - Fax:361-528-3542
Practice Address - Street 1:202 GREEN AVE
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:TX
Practice Address - Zip Code:78390-2706
Practice Address - Country:US
Practice Address - Phone:361-528-3018
Practice Address - Fax:361-528-3542
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1036226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0876815-01Medicaid
TX0876815-01Medicaid