Provider Demographics
NPI:1992078612
Name:POLANCO, SOFIA
Entity type:Individual
Prefix:
First Name:SOFIA
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 1:1 OAKWOOD BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1956
Mailing Address - Country:US
Mailing Address - Phone:954-925-3844
Mailing Address - Fax:954-925-3845
Practice Address - Street 1:1 OAKWOOD BLVD
Practice Address - Street 2:STE 130
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1956
Practice Address - Country:US
Practice Address - Phone:954-925-3844
Practice Address - Fax:954-925-3845
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11940224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant