1386881258 NPI number — MARY Z PONCE

Table of content: (NPI 1386881258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386881258 NPI number — MARY Z PONCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY Z PONCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386881258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5835 CALLAGHAN RD
Provider Second Line Business Mailing Address:
SUITE 322
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78228-1125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-233-1566
Provider Business Mailing Address Fax Number:
210-547-7780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5835 CALLAGHAN RD
Provider Second Line Business Practice Location Address:
SUITE 322
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78228-1125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-233-1566
Provider Business Practice Location Address Fax Number:
210-547-7780
Provider Enumeration Date:
01/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PONCE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ZOILA
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
210-233-1566

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  30933 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1519050 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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