Provider Demographics
NPI:1265941678
Name:POLANCO, MELVINSON
Entity type:Individual
Prefix:
First Name:MELVINSON
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 SANBORN ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1229
Mailing Address - Country:US
Mailing Address - Phone:978-869-6383
Mailing Address - Fax:
Practice Address - Street 1:170 SANBORN ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-869-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool