Provider Demographics
NPI:1730725433
Name:POLLY, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
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 1:13246 NITI DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-2972
Mailing Address - Country:US
Mailing Address - Phone:727-271-9886
Mailing Address - Fax:
Practice Address - Street 1:40347 US HIGHWAY 19 N STE 103
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4841
Practice Address - Country:US
Practice Address - Phone:727-330-8932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician