NPIMap

Individual provider Active NPI

Kathy Polise

  • Social Worker
  • Grand Rapids, MI
National Provider Identifier
1053703157
Registry record updated Feb 26, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Social WorkerTaxonomy code 104100000X
License
6801058427 Issued in MI
Practice address
4255 Kalamazoo Ave SE
Grand Rapids, MI 49508-3638
Phone
(616) 455-0960
Fax
(616) 455-7324
NPI assigned
Feb 26, 2015
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 26, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Social Worker 104100000X 6801058427 MI Primary

Addresses

Primary practice location

4255 Kalamazoo Ave SE
Grand Rapids, MI 49508-3638

Mailing address

7428 Medinah Dr
Hudsonville, MI 49426-7561
Phone (616) 455-0960

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
6801058427MIMDSocial Worker

Practice roles

OrganizationSpecialtyStatusNew patients
Kent County CMH Authority Past Accepting new patients
Thresholds Inc PastSince Jul 26, 2010 Accepting new patients

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1424908800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1424908800000",
    "number": "1053703157",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7428 MEDINAH DR",
            "city": "HUDSONVILLE",
            "state": "MI",
            "postal_code": "494267561",
            "telephone_number": "616-455-0960",
            "fax_number": "616-455-7324"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4255 KALAMAZOO AVE SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495083638",
            "telephone_number": "616-455-0960",
            "fax_number": "616-455-7324"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POLISE",
        "first_name": "KATHY",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-02-26",
        "last_updated": "2015-02-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "MI",
            "license": "6801058427",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.