Provider Demographics
NPI:1578024253
Name:POLEWSKI, JUSTINE SANDRA (RBT)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:SANDRA
Last Name:POLEWSKI
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 NW 30TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33993-8640
Mailing Address - Country:US
Mailing Address - Phone:239-671-1122
Mailing Address - Fax:
Practice Address - Street 1:8701 MAITLAND SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5915
Practice Address - Country:US
Practice Address - Phone:407-574-4629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80036106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician