Provider Demographics
NPI:1295289486
Name:POLK, LATORIE
Entity type:Individual
Prefix:MRS
First Name:LATORIE
Middle Name:
Last Name:POLK
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 1:2380 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-1847
Mailing Address - Country:US
Mailing Address - Phone:731-287-1794
Mailing Address - Fax:
Practice Address - Street 1:1997 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3630
Practice Address - Country:US
Practice Address - Phone:901-476-8967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No104100000XBehavioral Health & Social Service ProvidersSocial Worker