Provider Demographics
NPI:1104417948
Name:POLING THERAPEUTIC GROUP LLC
Entity type:Organization
Organization Name:POLING THERAPEUTIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:POLING
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:540-830-1777
Mailing Address - Street 1:187 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SIDNEY
Mailing Address - State:VA
Mailing Address - Zip Code:24467-2205
Mailing Address - Country:US
Mailing Address - Phone:540-830-1777
Mailing Address - Fax:540-466-1770
Practice Address - Street 1:3617 BUTTERMILK CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22802-1022
Practice Address - Country:US
Practice Address - Phone:540-830-1777
Practice Address - Fax:540-466-1770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty