Provider Demographics
NPI:1134459092
Name:POLK, FAITH (SWT)
Entity Type:Individual
Prefix:MS
First Name:FAITH
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22266 CIVIC CENTER DR
Mailing Address - Street 2:# 204
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2622
Mailing Address - Country:US
Mailing Address - Phone:313-247-7250
Mailing Address - Fax:
Practice Address - Street 1:22266 CIVIC CENTER DR
Practice Address - Street 2:# 204
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2622
Practice Address - Country:US
Practice Address - Phone:313-247-7250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803060542171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator