Provider Demographics
NPI:1093328577
Name:PONICK, ALEXA MACKENZIE
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:MACKENZIE
Last Name:PONICK
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 1:198 ULLERY RD
Mailing Address - Street 2:
Mailing Address - City:CARMICHAELS
Mailing Address - State:PA
Mailing Address - Zip Code:15320-2448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 EDWIN ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-8505
Practice Address - Country:US
Practice Address - Phone:304-292-0173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0848235Z00000X
WV2193235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist