Provider Demographics
NPI:1457522872
Name:PONCE, MARA TAVERAS
Entity Type:Individual
Prefix:MRS
First Name:MARA
Middle Name:TAVERAS
Last Name:PONCE
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 1:1029 AVE J T PINERO
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PUERTO NUEVO
Mailing Address - State:PR
Mailing Address - Zip Code:00920-5612
Mailing Address - Country:US
Mailing Address - Phone:787-642-8844
Mailing Address - Fax:
Practice Address - Street 1:1029 AVE J T PINERO
Practice Address - Street 2:SUITE 203
Practice Address - City:PUERTO NUEVO
Practice Address - State:PR
Practice Address - Zip Code:00920-5612
Practice Address - Country:US
Practice Address - Phone:787-642-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2915103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool