Provider Demographics
NPI:1437387537
Name:POLIVICK, RITA IRENE (MS, LCSW,)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:IRENE
Last Name:POLIVICK
Suffix:
Gender:F
Credentials:MS, LCSW,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9532
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46899-9532
Mailing Address - Country:US
Mailing Address - Phone:260-437-1248
Mailing Address - Fax:
Practice Address - Street 1:3010 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4700
Practice Address - Country:US
Practice Address - Phone:260-471-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003316A101YM0800X
FLMH4219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health