Provider Demographics
NPI:1750442208
Name:PONCE, MARIO RICARDO (MA, MFT)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:RICARDO
Last Name:PONCE
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2353 PRUNERIDGE AVE
Mailing Address - Street 2:#9
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050
Mailing Address - Country:US
Mailing Address - Phone:408-649-1251
Mailing Address - Fax:408-249-9010
Practice Address - Street 1:70 WEST HEDDING STREET
Practice Address - Street 2:COUNTY OF SANTA CLARA
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110
Practice Address - Country:US
Practice Address - Phone:408-494-1561
Practice Address - Fax:408-494-1535
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA72341101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health