Provider Demographics
NPI:1356005045
Name:PONTES, ANGELISA FARIAS
Entity Type:Individual
Prefix:MRS
First Name:ANGELISA
Middle Name:FARIAS
Last Name:PONTES
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 1:11660 NW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33323-1858
Mailing Address - Country:US
Mailing Address - Phone:954-629-7850
Mailing Address - Fax:
Practice Address - Street 1:13650 NW 8TH ST STE 109
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6239
Practice Address - Country:US
Practice Address - Phone:954-289-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty