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 1:507 7TH ST STE 213
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1125
Mailing Address - Country:US
Mailing Address - Phone:712-870-1445
Mailing Address - Fax:712-248-8866
Practice Address - Street 1:507 7TH ST STE 213
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1125
Practice Address - Country:US
Practice Address - Phone:712-870-1445
Practice Address - Fax:712-248-8866
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001074101YM0800X
NE965101YA0400X
NE1139101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)