Provider Demographics
NPI:1417300468
Name:PONSFORD, MATTHEW (MA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PONSFORD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 NW MAPLE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8127
Mailing Address - Country:US
Mailing Address - Phone:206-719-8230
Mailing Address - Fax:
Practice Address - Street 1:1740 NW MAPLE ST STE 210
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8127
Practice Address - Country:US
Practice Address - Phone:206-719-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60769223103TC0700X
WAMC60679555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health