Provider Demographics
NPI:1790217925
Name:PEDRAZA POLANCO, MIREYA
Entity Type:Individual
Prefix:
First Name:MIREYA
Middle Name:
Last Name:PEDRAZA POLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 COMMERCE WAY STE 310
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1532
Mailing Address - Country:US
Mailing Address - Phone:305-827-2822
Mailing Address - Fax:305-827-2819
Practice Address - Street 1:14411 COMMERCE WAY STE 310
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-1532
Practice Address - Country:US
Practice Address - Phone:305-827-2822
Practice Address - Fax:305-827-2819
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician