Provider Demographics
NPI:1871127605
Name:POLANCO, KATIE (LMSW)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 BILTMORE LN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-6463
Mailing Address - Country:US
Mailing Address - Phone:917-287-3635
Mailing Address - Fax:
Practice Address - Street 1:4080 MCGINNIS FERRY RD STE 1304
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3951
Practice Address - Country:US
Practice Address - Phone:678-740-3990
Practice Address - Fax:844-903-4670
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103181-1104100000X
GAMSW010062104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker