=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639254808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARJORIE CAROLYN POLYS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2514 BIDDLE ST
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-7891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-365-2417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3828 TRUMBULL ST
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48183-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-675-8367
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801087436
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------