Provider Demographics
NPI:1235788050
Name:PONDER, ROSE MARY
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
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 1:2019 N WOODS ST
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-2753
Mailing Address - Country:US
Mailing Address - Phone:903-819-5851
Mailing Address - Fax:
Practice Address - Street 1:4045 NW 64TH ST STE 520
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-8608
Practice Address - Country:US
Practice Address - Phone:405-842-4911
Practice Address - Fax:405-842-5807
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
OK4970104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical