Provider Demographics
NPI:1972988533
Name:WELCH, POLLY PAULA
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:PAULA
Last Name:WELCH
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 1:1080 MARINA VILLAGE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1078
Mailing Address - Country:US
Mailing Address - Phone:510-337-7950
Mailing Address - Fax:
Practice Address - Street 1:11705 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4023
Practice Address - Country:US
Practice Address - Phone:323-568-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5131101Y00000X
CA171M00000X, 171M00000X
CA108313106H00000X
251B00000X
CA259895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management