Provider Demographics
NPI:1700494820
Name:POLANCO, MARIA LUISA
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:LUISA
Last Name:POLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:LUISA
Other - Last Name:ALEGRIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1721 GRIFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3312
Mailing Address - Country:US
Mailing Address - Phone:323-221-4134
Mailing Address - Fax:
Practice Address - Street 1:1721 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-3312
Practice Address - Country:US
Practice Address - Phone:323-221-4134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105055101YM0800X
390200000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program