Provider Demographics
NPI:1831903822
Name:PONGRATZ, RICK (PHD)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:PONGRATZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 N GALE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-7238
Mailing Address - Country:US
Mailing Address - Phone:208-220-1974
Mailing Address - Fax:
Practice Address - Street 1:1138 N GALE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-7238
Practice Address - Country:US
Practice Address - Phone:208-220-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202289103TC1900X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling