Provider Demographics
NPI:1861572380
Name:POLK, MIA L (LMSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:L
Last Name:POLK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:L
Other - Last Name:HAMPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:4702 W COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7068
Mailing Address - Country:US
Mailing Address - Phone:501-812-5545
Mailing Address - Fax:501-812-5546
Practice Address - Street 1:4702 W COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7068
Practice Address - Country:US
Practice Address - Phone:501-812-5545
Practice Address - Fax:501-812-5546
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1925-M104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker