Healthcare Provider Details

I. General information

NPI: 1013244151
Provider Name (Legal Business Name): GEORGE REGINALD POLK LPC; LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 N COURSE DR APT 305
POMPANO BEACH FL
33069-3370
US

IV. Provider business mailing address

3095 N COURSE DR APT 305
POMPANO BEACH FL
33069-3370
US

V. Phone/Fax

Practice location:
  • Phone: 170-357-7438
  • Fax: 954-366-3539
Mailing address:
  • Phone: 703-577-4389
  • Fax: 954-366-3539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17414
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004680
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: