Provider Demographics
NPI:1104486117
Name:POLK, EDWINA DENISE (LPC)
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:DENISE
Last Name:POLK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 AUSTIN DEKOTA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-2156
Mailing Address - Country:US
Mailing Address - Phone:704-320-8766
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6001
Practice Address - Country:US
Practice Address - Phone:704-320-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11379101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health