Provider Demographics
NPI:1003146739
Name:POLOVINA, CONNIE G (LCSW- C)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:G
Last Name:POLOVINA
Suffix:
Gender:F
Credentials:LCSW- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PEMBERTON DR STE 1C
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-2401
Mailing Address - Country:US
Mailing Address - Phone:410-845-1645
Mailing Address - Fax:443-944-8252
Practice Address - Street 1:1201 PEMBERTON DR STE 1C
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2401
Practice Address - Country:US
Practice Address - Phone:410-845-1645
Practice Address - Fax:443-944-8252
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD160641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical