Provider Demographics
NPI:1235722760
Name:MARCHANTE POLO, LIANE
Entity Type:Individual
Prefix:
First Name:LIANE
Middle Name:
Last Name:MARCHANTE POLO
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 1:1229 SE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1953
Mailing Address - Country:US
Mailing Address - Phone:786-449-5926
Mailing Address - Fax:
Practice Address - Street 1:1229 SE 23RD AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1953
Practice Address - Country:US
Practice Address - Phone:786-449-5926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-139906106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113807500Medicaid