Provider Demographics
NPI:1003528878
Name:PONTIKES, GWEN AILEEN
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:AILEEN
Last Name:PONTIKES
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 1:2206 BELMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37212-5106
Mailing Address - Country:US
Mailing Address - Phone:773-988-9220
Mailing Address - Fax:
Practice Address - Street 1:8283 RIVER ROAD PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-6009
Practice Address - Country:US
Practice Address - Phone:615-356-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health