Provider Demographics
NPI:1245595529
Name:PONCIANO, MARTIN AMABLE (LVN, LMFT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:AMABLE
Last Name:PONCIANO
Suffix:
Gender:M
Credentials:LVN, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 MISSION GORGE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3425
Mailing Address - Country:US
Mailing Address - Phone:619-481-5200
Mailing Address - Fax:
Practice Address - Street 1:6160 MISSION GORGE RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3425
Practice Address - Country:US
Practice Address - Phone:619-481-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN206256164X00000X
CAMFC 96247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No164X00000XNursing Service ProvidersLicensed Vocational Nurse