Provider Demographics
NPI:1245595529
Name:PONCIANO, MARTIN AMABLE (RN, LMFT)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:AMABLE
Last Name:PONCIANO
Suffix:
Gender:M
Credentials:RN, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN ST # 945
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-9998
Mailing Address - Country:US
Mailing Address - Phone:619-274-1682
Mailing Address - Fax:
Practice Address - Street 1:2250 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1402
Practice Address - Country:US
Practice Address - Phone:831-600-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 96247106H00000X
CA95259414163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist