Basic Information
| Provider Information | |||||||||
| NPI: | 1043511843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONCE | ||||||||
| FirstName: | LILIANA | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PANDURO | ||||||||
| OtherFirstName: | LILIANA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 737 RED ALDER PL | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920271886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022321445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2351 CARDINAL LN | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921233743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585732227 | ||||||||
| FaxNumber: | 8584962113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 90990 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 90990 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.