Provider Demographics
NPI:1750849840
Name:PONDER, SUSAN G
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:PONDER
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 130692
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0692
Mailing Address - Country:US
Mailing Address - Phone:214-926-6988
Mailing Address - Fax:
Practice Address - Street 1:1530 S SW LOOP 323 STE 104
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2558
Practice Address - Country:US
Practice Address - Phone:214-926-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health