Provider Demographics
NPI:1285196402
Name:POLTER, YAAKOV Y (MS LLPC)
Entity Type:Individual
Prefix:
First Name:YAAKOV
Middle Name:Y
Last Name:POLTER
Suffix:
Gender:M
Credentials:MS LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17320 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2100
Mailing Address - Country:US
Mailing Address - Phone:248-200-9892
Mailing Address - Fax:
Practice Address - Street 1:17320 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2100
Practice Address - Country:US
Practice Address - Phone:248-727-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016245101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health