MEDICARE: MS. CONNIE JEAN POLLOCK L,I.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-0007011	OH

General Provider Information

NPI Number	:	1205817541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CONNIE JEAN POLLOCK L,I.S.W.

Provider Business Mailing Address
First Line	:	2197 KYLE LN
Second Line	:
City	:	FAIRBORN
State	:	OH
Zip	:	45324-6418
Country	:	US
Telephone Number	:	937-236-8920
Fax Number	:	937-236-8930

Provider Business Practice Location Address
First Line	:	4710 OLD TROY PIKE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-5740
Country	:	US
Telephone Number	:	937-233-1230
Fax Number	:	937-236-8930

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	07/08/2007

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