Basic Information
Provider Information | |||||||||
NPI: | 1427057579 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POLSON | ||||||||
FirstName: | MICHOL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 501 MAIN ST, SUITE 207 | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 97601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412239417 | ||||||||
FaxNumber: | 5418822583 | ||||||||
Practice Location | |||||||||
Address1: | 501 MAIN ST, SUITE 207 | ||||||||
Address2: |   | ||||||||
City: | KLAMATH FALLS | ||||||||
State: | OR | ||||||||
PostalCode: | 97601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412239417 | ||||||||
FaxNumber: | 5418822583 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2005 | ||||||||
LastUpdateDate: | 03/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT000940 | GA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 106H00000X | 845 | TN | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 106H00000X | T0815 | OR | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 500649144 | 05 | OR |   | MEDICAID |