Provider Demographics
NPI:1508411034
Name:POULOGIANNI, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:POULOGIANNI
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 1:1 IKE CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3005
Mailing Address - Country:US
Mailing Address - Phone:650-559-4166
Mailing Address - Fax:
Practice Address - Street 1:1 IKE CT
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3005
Practice Address - Country:US
Practice Address - Phone:650-559-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician