Provider Demographics
NPI:1639484280
Name:ASTORGA, POLLY ANNE (MFT)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ANNE
Last Name:ASTORGA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 S INTERSTATE PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-8601
Mailing Address - Country:US
Mailing Address - Phone:385-236-4500
Mailing Address - Fax:
Practice Address - Street 1:170 S INTERSTATE PLZ STE 100
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-8601
Practice Address - Country:US
Practice Address - Phone:385-236-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT367155-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist