Provider Demographics
NPI:1679041321
Name:CARTAGENA PONCIANO, STEPHANY ALEXANDRA (LGPC)
Entity Type:Individual
Prefix:
First Name:STEPHANY
Middle Name:ALEXANDRA
Last Name:CARTAGENA PONCIANO
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19410 FISHER AVE
Mailing Address - Street 2:
Mailing Address - City:POOLESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20837-2256
Mailing Address - Country:US
Mailing Address - Phone:620-481-3133
Mailing Address - Fax:
Practice Address - Street 1:19410 FISHER AVE
Practice Address - Street 2:
Practice Address - City:POOLESVILLE
Practice Address - State:MD
Practice Address - Zip Code:20837-2256
Practice Address - Country:US
Practice Address - Phone:620-481-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9096101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional