Provider Demographics
NPI:1437294279
Name:PONCE, THERESA G (LPT)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:G
Last Name:PONCE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WENSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3954
Mailing Address - Country:US
Mailing Address - Phone:760-353-8910
Mailing Address - Fax:
Practice Address - Street 1:202 N 8TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2302
Practice Address - Country:US
Practice Address - Phone:760-482-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26962167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician