=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134007172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA LAVIECE POLK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 W 5TH ST
-----------------------------------------------------
City | PORTALES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88130-6329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-356-7075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 E PLAZA DR
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-3534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-791-2725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SAH-2025-0263
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------