Provider Demographics
NPI:1831824838
Name:EVORA-POLANCO, ISADORA DANIA (MSW)
Entity type:Individual
Prefix:
First Name:ISADORA
Middle Name:DANIA
Last Name:EVORA-POLANCO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 WILLOWBAY RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6740
Mailing Address - Country:US
Mailing Address - Phone:646-228-3621
Mailing Address - Fax:
Practice Address - Street 1:358 WILLOWBAY RIDGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6740
Practice Address - Country:US
Practice Address - Phone:646-228-3621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL222Q00000XOtherPRIMARY TAXONOMY