Provider Demographics
NPI:1649850942
Name:POLANCO, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name: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 1:385 46TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-1916
Mailing Address - Country:US
Mailing Address - Phone:516-473-3627
Mailing Address - Fax:
Practice Address - Street 1:385 46TH ST APT 2
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1916
Practice Address - Country:US
Practice Address - Phone:516-473-3627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2023-07-05
Deactivation Date:2022-10-19
Deactivation Code:
Reactivation Date:2022-11-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral