Healthcare Provider Details

I. General information

NPI: 1104092014
Provider Name (Legal Business Name): KELLEY J POLK LIMHP,LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 7TH ST STE 213
SIOUX CITY IA
51101-1125
US

IV. Provider business mailing address

507 7TH ST STE 213
SIOUX CITY IA
51101-1125
US

V. Phone/Fax

Practice location:
  • Phone: 712-870-1445
  • Fax: 712-248-8866
Mailing address:
  • Phone: 712-870-1445
  • Fax: 712-248-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number965
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001074
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1139
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: