Provider Demographics
NPI:1770131229
Name:POLSTRA, MARVIN LOUIS (LCSW)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:LOUIS
Last Name:POLSTRA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:POLSTRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:3505 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3718
Mailing Address - Country:US
Mailing Address - Phone:317-920-5900
Mailing Address - Fax:317-920-5911
Practice Address - Street 1:3505 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-3718
Practice Address - Country:US
Practice Address - Phone:317-920-5900
Practice Address - Fax:317-920-5911
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002649A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical