Provider Demographics
NPI:1710215074
Name:POLOSS, ENJIL (MS)
Entity Type:Individual
Prefix:
First Name:ENJIL
Middle Name:
Last Name:POLOSS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E OLIVE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1214
Mailing Address - Country:US
Mailing Address - Phone:818-823-6677
Mailing Address - Fax:626-737-6034
Practice Address - Street 1:12821 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3012
Practice Address - Country:US
Practice Address - Phone:818-432-5025
Practice Address - Fax:818-760-9092
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA109540106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA109540OtherBBS