Provider Demographics
NPI:1467775882
Name:PONCELET, ANGELIQUE MARY (LPC)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MARY
Last Name:PONCELET
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1753 SIDEWINDER DR # S200
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7258
Mailing Address - Country:US
Mailing Address - Phone:435-649-9079
Mailing Address - Fax:
Practice Address - Street 1:1753 SIDEWINDER DR # S200
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7258
Practice Address - Country:US
Practice Address - Phone:435-649-9079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6822558-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional