Provider Demographics
NPI:1750633079
Name:HORMEL, POLLY
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:HORMEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4668
Mailing Address - Country:US
Mailing Address - Phone:831-462-1060
Mailing Address - Fax:831-460-4970
Practice Address - Street 1:200 7TH AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4668
Practice Address - Country:US
Practice Address - Phone:831-462-1060
Practice Address - Fax:831-460-4970
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)