Provider Demographics
NPI:1750663688
Name:PONISH, CHARLOTTE D (LPC)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:D
Last Name:PONISH
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:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-0491
Mailing Address - Country:US
Mailing Address - Phone:361-649-1454
Mailing Address - Fax:979-529-9853
Practice Address - Street 1:115 N DIXIE DR STE 250
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5906
Practice Address - Country:US
Practice Address - Phone:361-649-1454
Practice Address - Fax:979-529-9853
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64264101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX64264OtherLPC LICENSE