Provider Demographics
NPI:1518325448
Name:POLK, CAROLYN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5044
Mailing Address - Country:US
Mailing Address - Phone:573-803-1402
Mailing Address - Fax:573-803-1405
Practice Address - Street 1:400 N WASHINGTON ST
Practice Address - Street 2:SUITE 116
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1716
Practice Address - Country:US
Practice Address - Phone:573-218-9653
Practice Address - Fax:573-803-1405
Is Sole Proprietor?:No
Enumeration Date:2016-02-06
Last Update Date:2016-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013002023101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional