Provider Demographics
NPI:1942359864
Name:PONCE, CONNIE JO (PSYD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
Last Name:PONCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127B STATE HWY 14 N STE 5
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9557
Mailing Address - Country:US
Mailing Address - Phone:505-944-9495
Mailing Address - Fax:505-207-2539
Practice Address - Street 1:12127B STATE HWY 14 N STE 5
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9557
Practice Address - Country:US
Practice Address - Phone:412-475-8845
Practice Address - Fax:505-207-2539
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM-0926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical