Provider Demographics
NPI:1831359587
Name:POLLYEA, MARY DENNISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:DENNISE
Last Name:POLLYEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 RED OAK LANE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AR
Mailing Address - Zip Code:72641
Mailing Address - Country:US
Mailing Address - Phone:870-446-6449
Mailing Address - Fax:
Practice Address - Street 1:105 RED OAK LANE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AR
Practice Address - Zip Code:72641
Practice Address - Country:US
Practice Address - Phone:870-446-6449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA37791041C0700X
AR2220C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical