Provider Demographics
NPI:1538929955
Name:POLANCO GOMEZ, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:POLANCO GOMEZ
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 1:977 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5716
Mailing Address - Country:US
Mailing Address - Phone:786-583-6822
Mailing Address - Fax:
Practice Address - Street 1:977 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5716
Practice Address - Country:US
Practice Address - Phone:786-583-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-316330106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician