Basic Information
| Provider Information | |||||||||
| NPI: | 1720391188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | CYNTHIA | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716555723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703672461 | ||||||||
| FaxNumber: | 8703672363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | CROSSETT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703646471 | ||||||||
| FaxNumber: | 8703649753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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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 | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 5292-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.