Provider Demographics
NPI:1275369902
Name:POLK, KELSEY CARIN (AMFT/APCC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:CARIN
Last Name:POLK
Suffix:
Gender:F
Credentials:AMFT/APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12021 WILMINGTON AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3019
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:222 S HILL ST STE 600
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3523
Practice Address - Country:US
Practice Address - Phone:213-255-9753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT149539106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist