Basic Information
| Provider Information | |||||||||
| NPI: | 1558576678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLAN | ||||||||
| FirstName: | INDIRA ANN | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 CENTRAL PARK DR APT 2432 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956783526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309136851 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9089 CLAIREMONT MESA BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT8593 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 157462721 | 05 | AR | MEDICAID |