Provider Demographics
NPI:1407364060
Name:POLANCO, MARCUS A (MS ED)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:A
Last Name:POLANCO
Suffix:
Gender:M
Credentials:MS ED
Other - Prefix:MR
Other - First Name:MARCUS
Other - Middle Name:A
Other - Last Name:POLANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS ED
Mailing Address - Street 1:824 SAINT NICHOLAS AVE APT 32
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-1922
Mailing Address - Country:US
Mailing Address - Phone:646-416-2011
Mailing Address - Fax:
Practice Address - Street 1:224 W 35TH ST FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2533
Practice Address - Country:US
Practice Address - Phone:929-266-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1190777171103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst