Provider Demographics
NPI:1194587402
Name:POLKA DOT JOURNEY LLC
Entity type:Organization
Organization Name:POLKA DOT JOURNEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:346-229-7788
Mailing Address - Street 1:7740 W LITTLE YORK RD APT 2624
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-5489
Mailing Address - Country:US
Mailing Address - Phone:346-229-7788
Mailing Address - Fax:
Practice Address - Street 1:7740 W LITTLE YORK RD APT 2624
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-5489
Practice Address - Country:US
Practice Address - Phone:346-229-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center