Provider Demographics
NPI:1225238488
Name:POLANCO, GAMALIEL
Entity Type:Individual
Prefix:
First Name:GAMALIEL
Middle Name:
Last Name: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 1:5807 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-5303
Mailing Address - Country:US
Mailing Address - Phone:323-234-4445
Mailing Address - Fax:
Practice Address - Street 1:5807 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5303
Practice Address - Country:US
Practice Address - Phone:323-234-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW22095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health