Provider Demographics
NPI:1740681964
Name:POLKINGHORN, ROBERTA (MA, CMHC, LPC, CPC,)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:
Last Name:POLKINGHORN
Suffix:
Gender:F
Credentials:MA, CMHC, LPC, CPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 E OWENWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5381
Mailing Address - Country:US
Mailing Address - Phone:801-518-3554
Mailing Address - Fax:
Practice Address - Street 1:1553 E OWENWOOD CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-5381
Practice Address - Country:US
Practice Address - Phone:801-518-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-07
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10728504-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701011742OtherLPC
267724OtherNCC
UT10728504-6004OtherCMHC
NVCP5288-ROtherCPC