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General NPI Number Information
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NPI Number | 1013244151
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Entity Type | Individual
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Provider Name | GEORGE REGINALD POLK LPC; LMHC
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Gender | Male
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Dates
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Enumeration Date | 11/11/2009
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Last Update Date | 11/17/2020
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Provider Practice Location Address
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Address Line | 3095 N COURSE DR APT 305
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3370
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Country | US
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Telephone | 170-357-7438
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Fax | 954-366-3539
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Provider Business Mailing Address
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Address Line | 3095 N COURSE DR APT 305
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3370
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Country | US
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Telephone | 703-577-4389
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Fax | 954-366-3539
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH17414
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701004680
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License Number State | VA
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