Provider Demographics
NPI:1689774226
Name:POLENZ, DOUGLAS D (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:D
Last Name:POLENZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5101
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-253-8891
Practice Address - Street 1:1930 S ALMA SCHOOL RD
Practice Address - Street 2:STE. A104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3064
Practice Address - Country:US
Practice Address - Phone:480-820-0825
Practice Address - Fax:480-820-7863
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0797101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR20602Medicare UPIN
AZPHD797Medicare ID - Type Unspecified