Provider Demographics
NPI:1386419844
Name:POLANCO, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:POLANCO
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 1:2304 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-4411
Mailing Address - Country:US
Mailing Address - Phone:347-415-7049
Mailing Address - Fax:
Practice Address - Street 1:2304 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4411
Practice Address - Country:US
Practice Address - Phone:844-222-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1037676Medicaid