Provider Demographics
NPI:1386915213
Name:POLK, JUDITH
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:POLK
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 1:3200 DORAL DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1282
Mailing Address - Country:US
Mailing Address - Phone:248-722-3867
Mailing Address - Fax:248-289-1196
Practice Address - Street 1:3200 DORAL DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1282
Practice Address - Country:US
Practice Address - Phone:248-722-3867
Practice Address - Fax:248-289-1196
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001925225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist