Provider Demographics
NPI:1376271486
Name:PONDECA, CLARA
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:PONDECA
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 1:929 N VAL VISTA DR STE 109
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-3701
Mailing Address - Country:US
Mailing Address - Phone:480-331-3231
Mailing Address - Fax:
Practice Address - Street 1:26120 N POSEIDON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-5537
Practice Address - Country:US
Practice Address - Phone:703-200-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320800000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness