Provider Demographics
NPI:1598181919
Name:POLANCO, STEFANIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CASA PARK COURT F
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5418
Mailing Address - Country:US
Mailing Address - Phone:954-303-0118
Mailing Address - Fax:
Practice Address - Street 1:2884 WELLNESS AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8397
Practice Address - Country:US
Practice Address - Phone:386-774-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13269224Z00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOT18866OtherOT LICENSE