Provider Demographics
NPI:1912133794
Name:POLK, RONNIE
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RONNIE
Other - Middle Name:
Other - Last Name:POLK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4754 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5812
Mailing Address - Country:US
Mailing Address - Phone:414-466-4101
Mailing Address - Fax:
Practice Address - Street 1:3353 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1455
Practice Address - Country:US
Practice Address - Phone:414-559-6121
Practice Address - Fax:141-445-7858
Is Sole Proprietor?:No
Enumeration Date:2009-06-06
Last Update Date:2009-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2931-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437325032OtherFEDERAL PROVIDER ID NUMBER