Provider Demographics
NPI:1104630672
Name:POLANCO, JOSHUA JOSUE
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JOSUE
Last Name:POLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5579
Mailing Address - Country:US
Mailing Address - Phone:907-360-5603
Mailing Address - Fax:
Practice Address - Street 1:1477 NC 24-87
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-6752
Practice Address - Country:US
Practice Address - Phone:910-484-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician