Provider Demographics
NPI:1164263711
Name:POLAK, ROMAN CHARLES (LSW)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:CHARLES
Last Name:POLAK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:YERINGTON
Mailing Address - State:NV
Mailing Address - Zip Code:89447-9745
Mailing Address - Country:US
Mailing Address - Phone:775-379-9514
Mailing Address - Fax:
Practice Address - Street 1:11 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:YERINGTON
Practice Address - State:NV
Practice Address - Zip Code:89447-9745
Practice Address - Country:US
Practice Address - Phone:775-379-9514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11011-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker