Provider Demographics
NPI:1629485594
Name:POLONI, LYDIA N (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:N
Last Name:POLONI
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:734-203-0181
Mailing Address - Fax:
Practice Address - Street 1:2890 CARPENTER RD STE 1100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1190
Practice Address - Country:US
Practice Address - Phone:734-715-9062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401000978103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty