Provider Demographics
NPI:1245389618
Name:CHAN, POLING (LCSW)
Entity Type:Individual
Prefix:
First Name:POLING
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3335
Mailing Address - Country:US
Mailing Address - Phone:970-226-6103
Mailing Address - Fax:
Practice Address - Street 1:504 S COLLEGE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3002
Practice Address - Country:US
Practice Address - Phone:970-481-7397
Practice Address - Fax:970-226-6103
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9926061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC445668Medicare ID - Type Unspecified