Provider Demographics
NPI:1245919786
Name:POLHEMUS, BLAIR (BCBA)
Entity type:Individual
Prefix:MRS
First Name:BLAIR
Middle Name:
Last Name:POLHEMUS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MISS
Other - First Name:BLAIR
Other - Middle Name:
Other - Last Name:BERARDESCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1479 EARIE WAY
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1970 SWARTHMORE AVE STE 4
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4553
Practice Address - Country:US
Practice Address - Phone:908-675-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-23-66424103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst