Provider Demographics
NPI:1801410170
Name:BLUE DANDELION INTEGRATIVE THERAPY, LLC
Entity Type:Organization
Organization Name:BLUE DANDELION INTEGRATIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DILIANA
Authorized Official - Middle Name:B
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-343-6773
Mailing Address - Street 1:4640 LIPSCOMB ST NE STE 5
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2986
Mailing Address - Country:US
Mailing Address - Phone:321-343-6773
Mailing Address - Fax:
Practice Address - Street 1:4640 LIPSCOMB ST NE STE 5
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2986
Practice Address - Country:US
Practice Address - Phone:321-343-6773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-02
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty