Provider Demographics
NPI:1760508774
Name:PONCE, MOISES (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:MOISES
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25742 VAN LEUVEN ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2508
Mailing Address - Country:US
Mailing Address - Phone:909-478-0701
Mailing Address - Fax:
Practice Address - Street 1:1688 N PERRIS BLVD
Practice Address - Street 2:SUITE L7-11
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-4709
Practice Address - Country:US
Practice Address - Phone:951-443-2236
Practice Address - Fax:951-443-2240
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39956106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA39956OtherIMF NUMBER