Provider Demographics
NPI:1053155390
Name:POLLY, MADISEN NICOLE
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:NICOLE
Last Name:POLLY
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 1:113 N CHESTNUT ST STE 301
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2197
Mailing Address - Country:US
Mailing Address - Phone:812-515-3160
Mailing Address - Fax:
Practice Address - Street 1:113 N CHESTNUT ST STE 301
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2197
Practice Address - Country:US
Practice Address - Phone:812-515-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health