Provider Demographics
NPI:1174777213
Name:POLANCO, IZILDA M (PHD)
Entity type:Individual
Prefix:DR
First Name:IZILDA
Middle Name:M
Last Name:POLANCO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 S ORANGE AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-3068
Mailing Address - Country:US
Mailing Address - Phone:407-240-7003
Mailing Address - Fax:407-240-7003
Practice Address - Street 1:5205 S ORANGE AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-3068
Practice Address - Country:US
Practice Address - Phone:407-240-7003
Practice Address - Fax:407-240-7003
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL06003101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health