Provider Demographics
NPI:1003126970
Name:POLK-WOOLFOLK, LISA (MS, LLPC, CAC-M)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:POLK-WOOLFOLK
Suffix:
Gender:F
Credentials:MS, LLPC, CAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 RIVARD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4740
Mailing Address - Country:US
Mailing Address - Phone:313-258-9713
Mailing Address - Fax:
Practice Address - Street 1:3731 RIVARD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4740
Practice Address - Country:US
Practice Address - Phone:313-258-9713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104717101YA0400X
MI6401012200101YP2500X
MI6802063821104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker