Provider Demographics
NPI:1841714177
Name:POLACEK, RICHARD KEITH (LBA, BCBA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KEITH
Last Name:POLACEK
Suffix:
Gender:M
Credentials:LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-3341
Mailing Address - Country:US
Mailing Address - Phone:401-413-0160
Mailing Address - Fax:
Practice Address - Street 1:30 CUMBERLAND ST.
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895
Practice Address - Country:US
Practice Address - Phone:401-413-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILBA00034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILBA00034OtherSTATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH
RI1-12-11616OtherBEHAVIOR ANALYST CERTIFICATION BOARD