Provider Demographics
NPI:1891316410
Name:PONCE, ENRIQUE
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3185 CORTE CABRILLO
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3162
Mailing Address - Country:US
Mailing Address - Phone:831-201-9491
Mailing Address - Fax:
Practice Address - Street 1:380 ENCINAL ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2178
Practice Address - Country:US
Practice Address - Phone:831-469-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health