Provider Demographics
NPI:1073079208
Name:POLK, MERCEDES LYNN (MERCEDES)
Entity Type:Individual
Prefix:MS
First Name:MERCEDES
Middle Name:LYNN
Last Name:POLK
Suffix:
Gender:F
Credentials:MERCEDES
Other - Prefix:MS
Other - First Name:MERCEDES
Other - Middle Name:LYNN
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2621 ROYAL STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030
Mailing Address - Country:US
Mailing Address - Phone:702-601-4005
Mailing Address - Fax:
Practice Address - Street 1:2621 ROYAL STREET
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030
Practice Address - Country:US
Practice Address - Phone:702-601-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health