Andrea Polk, PH D

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY11637 Issued in CA

Practice address

80 Eureka Square
Suite 124
Pacifica, CA 94044

Phone

(650) 359-0711

Fax

(650) 738-1246

NPI assigned

Aug 18, 2006

Sex

Female

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 1, 2017 through Oct 1, 2027

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Philosophy

State licenses

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

{
    "created_epoch": "1155859200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1790899581",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "80 EUREKA SQUARE",
            "address_2": "STE 124",
            "city": "PACIFICA",
            "state": "CA",
            "postal_code": "94044"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "80 EUREKA SQUARE",
            "address_2": "SUITE 124",
            "city": "PACIFICA",
            "state": "CA",
            "postal_code": "94044",
            "telephone_number": "650-359-0711",
            "fax_number": "650-738-1246"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POLK",
        "first_name": "ANDREA",
        "name_prefix": "Dr.",
        "credential": "PH D",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-18",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "CA",
            "license": "PSY11637",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VALUE OPTIONS",
            "identifier": "164390",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Pacifica, CA
• Providers in Pacifica, CA by specialty
• Clinical Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.