Provider Demographics
NPI:1285021667
Name:POLZIN, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:POLZIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MN
Mailing Address - Zip Code:55334-4478
Mailing Address - Country:US
Mailing Address - Phone:507-235-6070
Mailing Address - Fax:507-235-6074
Practice Address - Street 1:112 5TH ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334-4478
Practice Address - Country:US
Practice Address - Phone:507-235-6070
Practice Address - Fax:507-235-6074
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00969101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1285021667Medicaid