Healthcare Provider Details

I. General information

NPI: 1790899581
Provider Name (Legal Business Name): ANDREA POLK PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 EUREKA SQUARE SUITE 124
PACIFICA CA
94044
US

IV. Provider business mailing address

80 EUREKA SQUARE STE 124
PACIFICA CA
94044
US

V. Phone/Fax

Practice location:
  • Phone: 650-359-0711
  • Fax: 650-738-1246
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY11637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: