Provider Demographics
NPI:1437793361
Name:POLSTRA, JULI ANNA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JULI
Middle Name:ANNA
Last Name:POLSTRA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8543 STATE ROUTE 124
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-9262
Mailing Address - Country:US
Mailing Address - Phone:937-402-0775
Mailing Address - Fax:
Practice Address - Street 1:550 MIRABEAU ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-1617
Practice Address - Country:US
Practice Address - Phone:937-981-9243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.015056235Z00000X
OH08852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist