Provider Demographics
NPI:1003450404
Name:PONCE REYES, ROSALBA I
Entity Type:Individual
Prefix:
First Name:ROSALBA
Middle Name:I
Last Name:PONCE REYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187B SUNRISE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3781
Mailing Address - Country:US
Mailing Address - Phone:505-577-7685
Mailing Address - Fax:
Practice Address - Street 1:187B SUNRISE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3781
Practice Address - Country:US
Practice Address - Phone:505-577-7685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician