Provider Demographics
NPI:1003467952
Name:POLO-MADERO, JOSE EMILIO (RBT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:EMILIO
Last Name:POLO-MADERO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 SW 8TH ST APT 411
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-3891
Mailing Address - Country:US
Mailing Address - Phone:305-528-6974
Mailing Address - Fax:
Practice Address - Street 1:1475 SW 8TH ST APT 411
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-3891
Practice Address - Country:US
Practice Address - Phone:305-528-6974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-99364106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBACB513306OtherBACB