Basic Information
| Provider Information | |||||||||
| NPI: | 1053703157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLISE | ||||||||
| FirstName: | KATHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7428 MEDINAH DR | ||||||||
| Address2: | |||||||||
| City: | HUDSONVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494267561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164550960 | ||||||||
| FaxNumber: | 6164557324 | ||||||||
| Practice Location | |||||||||
| Address1: | 4255 KALAMAZOO AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495083638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164550960 | ||||||||
| FaxNumber: | 6164557324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2015 | ||||||||
| LastUpdateDate: | 02/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801058427 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.