Provider Demographics
NPI:1245805001
Name:PONDER-BROWN, TORI (LMT)
Entity Type:Individual
Prefix:
First Name:TORI
Middle Name:
Last Name:PONDER-BROWN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3683
Mailing Address - Country:US
Mailing Address - Phone:607-330-0957
Mailing Address - Fax:
Practice Address - Street 1:1201 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3683
Practice Address - Country:US
Practice Address - Phone:607-330-0957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031154225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist