Basic Information
| Provider Information | |||||||||
| NPI: | 1114099249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONCE | ||||||||
| FirstName: | ALEXA | ||||||||
| MiddleName: | KAREN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10436 42ND AVE | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113682535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179744553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9114 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113727920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187791600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 12/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 084906 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 077199 | 01 | NY | NYS LICENSE # | OTHER |