Basic Information
| Provider Information | |||||||||
| NPI: | 1790924033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PONCE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7204 SKYWAY | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959693280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308771965 | ||||||||
| FaxNumber: | 5308945791 | ||||||||
| Practice Location | |||||||||
| Address1: | 7204 SKYWAY | ||||||||
| Address2: | |||||||||
| City: | PARADISE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959693280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308771965 | ||||||||
| FaxNumber: | 5308945791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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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 | 1041C0700X | 60924 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.