Provider Demographics
NPI:1164502209
Name:POLVI, SUSAN (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:POLVI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 TEAKWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-1346
Mailing Address - Country:US
Mailing Address - Phone:971-600-8953
Mailing Address - Fax:
Practice Address - Street 1:2184 TEAKWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-1346
Practice Address - Country:US
Practice Address - Phone:971-600-8953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2628101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional