Provider Demographics
NPI:1073947644
Name:GONZALES PONCIANO, MARIA PRISCILA (MRS SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:PRISCILA
Last Name:GONZALES PONCIANO
Suffix:
Gender:F
Credentials:MRS SLP
Other - Prefix:MRS
Other - First Name:MARIA
Other - Middle Name:PRISCILA
Other - Last Name:GONZALES PONCIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS SLP
Mailing Address - Street 1:3439 BRUCKNER BLVD APT 3F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5249
Mailing Address - Country:US
Mailing Address - Phone:347-785-7584
Mailing Address - Fax:
Practice Address - Street 1:3439 BRUCKNER BLVD
Practice Address - Street 2:APT 4E
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5249
Practice Address - Country:US
Practice Address - Phone:347-785-7584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021761OtherOFFICE OF PROFFESSIIONS
NY021761OtherOFFICE OF PROFFESSIIONS