Provider Demographics
NPI:1013588854
Name:POLANCO ALLEN, MYRIRAM YVONNE (CSWA)
Entity Type:Individual
Prefix:
First Name:MYRIRAM
Middle Name:YVONNE
Last Name:POLANCO ALLEN
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CARLTON
Mailing Address - State:OR
Mailing Address - Zip Code:97111-9614
Mailing Address - Country:US
Mailing Address - Phone:503-891-7321
Mailing Address - Fax:
Practice Address - Street 1:510 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:OR
Practice Address - Zip Code:97111-9614
Practice Address - Country:US
Practice Address - Phone:503-891-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA102821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical