Provider Demographics
NPI:1356385926
Name:POLESHUCK, ELLEN L (PHD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:L
Last Name:POLESHUCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 668
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-2691
Mailing Address - Fax:585-242-8707
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0002
Practice Address - Country:US
Practice Address - Phone:585-275-2691
Practice Address - Fax:585-242-8707
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014029103T00000X, 207V00000X, 103TC0700X
NY14029103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0298561Medicaid
NYCC2439Medicare PIN