Provider Demographics
NPI:1104092014
Name:POLK, KELLEY J (LIMHP,LADC)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:J
Last Name:POLK
Suffix:
Gender:F
Credentials:LIMHP,LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SIOUX CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68776-3445
Mailing Address - Country:US
Mailing Address - Phone:402-494-0040
Mailing Address - Fax:402-494-0050
Practice Address - Street 1:625 E 39TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3445
Practice Address - Country:US
Practice Address - Phone:402-494-0040
Practice Address - Fax:402-494-0050
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE965101YA0400X
IA001074101YM0800X
NE3670101YM0800X
NE1139101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)