Provider Demographics
NPI:1356901284
Name:PON, MARY-ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY-ELLEN
Middle Name:
Last Name:PON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY-ELLEN
Other - Middle Name:
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2001 SERENTIY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660
Mailing Address - Country:US
Mailing Address - Phone:512-459-6417
Mailing Address - Fax:
Practice Address - Street 1:2001 SERENTIY DRIVE
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660
Practice Address - Country:US
Practice Address - Phone:512-459-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health