Provider Demographics
NPI:1043407836
Name:POLANCO, ALYSON
Entity Type:Individual
Prefix:
First Name:ALYSON
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 1:2200 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4223
Mailing Address - Country:US
Mailing Address - Phone:985-781-4545
Mailing Address - Fax:317-449-5783
Practice Address - Street 1:60 BRIMLEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-5148
Practice Address - Country:US
Practice Address - Phone:540-552-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006721225X00000X
OH006809171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist