Provider Demographics
NPI:1003403528
Name:PONCE MORENO, MARTA
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:PONCE MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 S HIGLEY RD STE 103-477
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1166
Mailing Address - Country:US
Mailing Address - Phone:267-213-9712
Mailing Address - Fax:
Practice Address - Street 1:10544 VALDOSTA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-6463
Practice Address - Country:US
Practice Address - Phone:267-213-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-4058235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist