Provider Demographics
NPI:1417194895
Name:POLENI, VICTORIA A (MSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:POLENI
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14107 BELDING RD NE
Mailing Address - Street 2:
Mailing Address - City:BELDING
Mailing Address - State:MI
Mailing Address - Zip Code:48809-9635
Mailing Address - Country:US
Mailing Address - Phone:616-901-0149
Mailing Address - Fax:
Practice Address - Street 1:600 3RD ST NW STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504
Practice Address - Country:US
Practice Address - Phone:616-901-0149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010641511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417194895Medicaid