Provider Demographics
NPI:1588672893
Name:PONTON, SUSAN ALLEN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ALLEN
Last Name:PONTON
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:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0809
Mailing Address - Country:US
Mailing Address - Phone:434-447-7447
Mailing Address - Fax:434-447-3057
Practice Address - Street 1:501 N MECKLENBURG AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-2024
Practice Address - Country:US
Practice Address - Phone:434-447-7447
Practice Address - Fax:434-447-3057
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003560101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010030692Medicaid
VA54-1977426OtherFEIN (SUB-S )
VA86353MOtherSENTARA PROVIDER NUMBER
VA104658OtherANTHEM PROVIDER NUMBER