Provider Demographics
NPI:1164564027
Name:PONTIUS, KYLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80951
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-0951
Mailing Address - Country:US
Mailing Address - Phone:714-957-1973
Mailing Address - Fax:714-957-1922
Practice Address - Street 1:1700 ADAMS AVE STE 214
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4865
Practice Address - Country:US
Practice Address - Phone:714-957-1973
Practice Address - Fax:714-957-1922
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14186103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist