Provider Demographics
NPI:1750879268
Name:WAHL-POLIVKA, ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:WAHL-POLIVKA
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 1:2702 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-2789
Mailing Address - Country:US
Mailing Address - Phone:925-695-9210
Mailing Address - Fax:
Practice Address - Street 1:2702 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519
Practice Address - Country:US
Practice Address - Phone:925-771-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist