Provider Demographics
NPI:1013405836
Name:DE LEON POLANCO, RUALDO RUBEN
Entity Type:Individual
Prefix:
First Name:RUALDO
Middle Name:RUBEN
Last Name:DE LEON 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 1:4909 SW WAITE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2326
Mailing Address - Country:US
Mailing Address - Phone:206-739-1140
Mailing Address - Fax:
Practice Address - Street 1:10001 17TH PL S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98168-1615
Practice Address - Country:US
Practice Address - Phone:206-766-6976
Practice Address - Fax:206-766-6993
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)