Provider Demographics
NPI:1790899581
Name:POLK, ANDREA (PH D)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:POLK
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 EUREKA SQUARE
Mailing Address - Street 2:STE 124
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 EUREKA SQUARE
Practice Address - Street 2:SUITE 124
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044
Practice Address - Country:US
Practice Address - Phone:650-359-0711
Practice Address - Fax:650-738-1246
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11637103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
164390OtherVALUE OPTIONS