Healthcare Provider Details

I. General information

NPI: 1669078887
Provider Name (Legal Business Name): KATHLEEN VIRGINIA POLK-ICKES MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 50TH STREET CT STE 202
GIG HARBOR WA
98335-8583
US

IV. Provider business mailing address

2306 197TH AVE SW
LAKEBAY WA
98349-9797
US

V. Phone/Fax

Practice location:
  • Phone: 253-280-9888
  • Fax:
Mailing address:
  • Phone: 140-689-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: