Provider Demographics
NPI:1497252597
Name:POLO, SUSAN KELLY (PCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KELLY
Last Name:POLO
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9995 N MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-5460
Mailing Address - Country:US
Mailing Address - Phone:561-775-9579
Mailing Address - Fax:772-220-9894
Practice Address - Street 1:100 W 20TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-6158
Practice Address - Country:US
Practice Address - Phone:561-775-9579
Practice Address - Fax:772-220-9894
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW114741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical