Provider Demographics
NPI:1669078887
Name:POLK-ICKES, KATHLEEN VIRGINIA (MSC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:VIRGINIA
Last Name:POLK-ICKES
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 197TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9797
Mailing Address - Country:US
Mailing Address - Phone:140-689-9642
Mailing Address - Fax:
Practice Address - Street 1:3208 50TH STREET CT STE 202
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-8583
Practice Address - Country:US
Practice Address - Phone:253-280-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health