Healthcare Provider Details

I. General information

NPI: 1457516502
Provider Name (Legal Business Name): CHRISTINA MARIE POLK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 DWIGHT ST APT 1
NEW HAVEN CT
06511-8717
US

IV. Provider business mailing address

119 DWIGHT ST APT 1
NEW HAVEN CT
06511-8717
US

V. Phone/Fax

Practice location:
  • Phone: 203-646-8664
  • Fax:
Mailing address:
  • Phone: 203-646-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCSW0000007246
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117385
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17648
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6174
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: