Healthcare Provider Details

I. General information

NPI: 1538835558
Provider Name (Legal Business Name): KEISHA SHERRIE POLONIO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 MILLENNIUM PKWY STE 1031
BRANDON FL
33511-4859
US

IV. Provider business mailing address

11126 S US HIGHWAY 41 UNIT 2054
GIBSONTON FL
33534-9794
US

V. Phone/Fax

Practice location:
  • Phone: 813-665-0235
  • Fax: 813-560-0452
Mailing address:
  • Phone: 813-665-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW23221
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: