Provider Demographics
NPI:1942786868
Name:PONGO, LYDIA CARISSA (LLPC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CARISSA
Last Name:PONGO
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4384 LAUREL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9311
Mailing Address - Country:US
Mailing Address - Phone:269-982-3832
Mailing Address - Fax:
Practice Address - Street 1:830 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1102
Practice Address - Country:US
Practice Address - Phone:269-982-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016718101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional