Provider Demographics
NPI:1508603234
Name:PONCE, MAURICE
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 WHALEY AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-1445
Mailing Address - Country:US
Mailing Address - Phone:949-891-4624
Mailing Address - Fax:
Practice Address - Street 1:4535 WHALEY AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-1445
Practice Address - Country:US
Practice Address - Phone:949-891-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15086032341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty