Provider Demographics
NPI:1073845145
Name:PONDER, PEGGY SANDERFORD
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SANDERFORD
Last Name:PONDER
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 1:4917 CLAIRMONT AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-4420
Mailing Address - Country:US
Mailing Address - Phone:205-585-1713
Mailing Address - Fax:
Practice Address - Street 1:2117 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-3107
Practice Address - Country:US
Practice Address - Phone:205-585-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11290101YP1600X
AL64106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist