Provider Demographics
NPI:1225325376
Name:POLK, EVELYN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 ROBLES WAY
Mailing Address - Street 2:#168
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-8039
Mailing Address - Country:US
Mailing Address - Phone:707-553-1971
Mailing Address - Fax:707-553-1969
Practice Address - Street 1:312 GEORGIA ST
Practice Address - Street 2:SUITE #225
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5964
Practice Address - Country:US
Practice Address - Phone:707-553-1971
Practice Address - Fax:707-553-1969
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT30084106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist