Provider Demographics
NPI:1801337340
Name:POLOKOFF-KREPS, PENNY MICHELE (BS, ABA)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:MICHELE
Last Name:POLOKOFF-KREPS
Suffix:
Gender:F
Credentials:BS, ABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 NAUTICA LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-5943
Mailing Address - Country:US
Mailing Address - Phone:561-693-7447
Mailing Address - Fax:
Practice Address - Street 1:5028 NAUTICA LAKE CIR
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-5943
Practice Address - Country:US
Practice Address - Phone:561-693-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician