Provider Demographics
NPI:1134587314
Name:POLO, LILLIAM
Entity type:Individual
Prefix:
First Name:LILLIAM
Middle Name:
Last Name:POLO
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 1:1626 W HWY 287 BUS STE 101
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-4728
Mailing Address - Country:US
Mailing Address - Phone:214-864-6988
Mailing Address - Fax:972-906-9112
Practice Address - Street 1:1626 W HWY 287 BUS STE 101
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-4728
Practice Address - Country:US
Practice Address - Phone:214-864-6988
Practice Address - Fax:972-906-9112
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12045101YM0800X, 174400000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013287721Medicaid