Healthcare Provider Details

I. General information

NPI: 1861572380
Provider Name (Legal Business Name): MIA L POLK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIA L HAMPTON MSW

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 W COMMERCIAL DR
NORTH LITTLE ROCK AR
72116-7068
US

IV. Provider business mailing address

4702 W COMMERCIAL DR
NORTH LITTLE ROCK AR
72116-7068
US

V. Phone/Fax

Practice location:
  • Phone: 501-812-5545
  • Fax: 501-812-5546
Mailing address:
  • Phone: 501-812-5545
  • Fax: 501-812-5546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1925-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: