Provider Demographics
NPI:1093480030
Name:POLU, MACKENZIE (RBT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:POLU
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18310 OLD COACH WAY
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-6636
Mailing Address - Country:US
Mailing Address - Phone:858-603-3341
Mailing Address - Fax:
Practice Address - Street 1:18310 OLD COACH WAY
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-6636
Practice Address - Country:US
Practice Address - Phone:858-603-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician