Basic Information
| Provider Information | |||||||||
| NPI: | 1568759777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MA LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12850 FOUNTAIN SQ | ||||||||
| Address2: | STE 106 | ||||||||
| City: | DAVISBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483502552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486346303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42669 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864125321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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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 | 101YP2500X | 640102524 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 750910402 | 01 | MI | BLUE CROSS | OTHER |