Basic Information
| Provider Information | |||||||||
| NPI: | 1689774226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLENZ | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 N 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850155101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | 6022538891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1930 S ALMA SCHOOL RD | ||||||||
| Address2: | STE. A104 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808200825 | ||||||||
| FaxNumber: | 4808207863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0797 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.