Provider Demographics
NPI:1750941555
Name:PONCE DE LEON, SYDNEY VIRGINIA
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:VIRGINIA
Last Name:PONCE DE LEON
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 1:495 WINN WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1710
Mailing Address - Country:US
Mailing Address - Phone:770-209-9826
Mailing Address - Fax:
Practice Address - Street 1:495 WINN WAY STE 210
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1710
Practice Address - Country:US
Practice Address - Phone:770-209-9826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002877235Z00000X
GASLP011023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist