Provider Demographics
NPI:1700556305
Name:POLAK, SAMANTHA KATHRYN (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:KATHRYN
Last Name:POLAK
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4944 NARRAGANSETT AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-6121
Mailing Address - Country:US
Mailing Address - Phone:908-309-4941
Mailing Address - Fax:
Practice Address - Street 1:9520 PADGETT ST STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4446
Practice Address - Country:US
Practice Address - Phone:858-866-8133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21013225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist