1962527408 NPI number — MRS. ELIZABETH MARIE POLOMIK LPC

Table of content: MRS. ELIZABETH MARIE POLOMIK LPC (NPI 1962527408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962527408 NPI number — MRS. ELIZABETH MARIE POLOMIK LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLOMIK
Provider First Name:
ELIZABETH
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOGAER
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962527408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3520 PRITCHARD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27616-8973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-266-9010
Provider Business Mailing Address Fax Number:
919-747-4172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8510 SIX FORKS RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27615-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-602-8572
Provider Business Practice Location Address Fax Number:
919-747-4172
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  5135 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6103070 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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