Provider Demographics
NPI:1821734278
Name:RUHLEN PONCE, SHELLEY ANITA (AMFT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANITA
Last Name:RUHLEN PONCE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433A FRESHWATER RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-9411
Mailing Address - Country:US
Mailing Address - Phone:707-499-3363
Mailing Address - Fax:
Practice Address - Street 1:381 BAYSIDE RD STE D
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-7102
Practice Address - Country:US
Practice Address - Phone:707-440-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT139952106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist