Provider Demographics
NPI:1184831281
Name:PONDER, TAMMY JO (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:PONDER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4323
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-0323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47872-1711
Practice Address - Country:US
Practice Address - Phone:765-569-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005386A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000532907OtherANTHEM BCBS
000000532907OtherANTHEM BCBS