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General NPI Number Information
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NPI Number | 1669078887
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Entity Type | Individual
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Provider Name | KATHLEEN VIRGINIA POLK-ICKES MSC
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Gender | Female
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Dates
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Enumeration Date | 12/11/2020
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Last Update Date | 12/11/2020
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Provider Practice Location Address
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Address Line | 3208 50TH STREET CT STE 202
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City | GIG HARBOR
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State | WA
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Zip | 98335-8583
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Country | US
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Telephone | 253-280-9888
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Fax |
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Provider Business Mailing Address
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Address Line | 2306 197TH AVE SW
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City | LAKEBAY
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State | WA
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Zip | 98349-9797
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Country | US
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Telephone | 140-689-9642
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Fax |
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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 |
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License Number State |
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