Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 104717 | MI |
Y | 101YP2500X | Professional Counselor | 6401012200 | MI |
N | 104100000X | Social Worker | 6802063821 | MI |
NPI | 1003126970 |
---|---|
Provider Name | Mrs. Lisa Polk-Woolfolk |
First Address | Detroit, MI 48207-4740 |
Second Address | Detroit, MI 48207-4740 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2010 |
Last Update Date | 13/10/2010 |