Healthcare Provider Details

I. General information

NPI: 1114645009
Provider Name (Legal Business Name): PODER HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 BROADWAY STE 630
NEW YORK NY
10034-1611
US

IV. Provider business mailing address

5030 BROADWAY STE 630
NEW YORK NY
10034-1611
US

V. Phone/Fax

Practice location:
  • Phone: 646-470-0639
  • Fax: 516-490-7472
Mailing address:
  • Phone: 646-470-0639
  • Fax: 516-490-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALEXMI POLANCO
Title or Position: OWNER/ LICENSED THERAPIST
Credential: LMHC
Phone: 646-470-0639