Provider Demographics
NPI:1619020344
Name:POLEN, NANCY B (LMFT)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:B
Last Name:POLEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11239 VILLA TRACE PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1711
Mailing Address - Country:US
Mailing Address - Phone:704-540-6317
Mailing Address - Fax:
Practice Address - Street 1:11239 VILLA TRACE PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1711
Practice Address - Country:US
Practice Address - Phone:704-540-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC857106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105071Medicaid