Provider Demographics
NPI:1013406701
Name:POLK, ZACHARY KANE (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:KANE
Last Name:POLK
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4249 HARTFORD ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1905
Mailing Address - Country:US
Mailing Address - Phone:601-201-6670
Mailing Address - Fax:
Practice Address - Street 1:5859 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3571
Practice Address - Country:US
Practice Address - Phone:314-669-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016036025106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist