Provider Demographics
NPI:1790455293
Name:MCCAUL, POLLY ANN (LLC)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ANN
Last Name:MCCAUL
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:ANN
Other - Last Name:FRENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:248-620-6405
Practice Address - Street 1:3744 28TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1802
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:248-620-6405
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017485101Y00000X
MI6451017485101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor