Healthcare Provider Details

I. General information

NPI: 1316797251
Provider Name (Legal Business Name): DAYLISE ALLEN-POLIDORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 CRYSTAL GROVE BLVD
LUTZ FL
33548-6409
US

IV. Provider business mailing address

9827 MONTAGUE ST
TAMPA FL
33626-1863
US

V. Phone/Fax

Practice location:
  • Phone: 813-848-0341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ13320
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSI6976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: