Provider Demographics
NPI:1881798171
Name:PERSONA NEURO BEHAVIOR GROUP INC.
Entity type:Organization
Organization Name:PERSONA NEURO BEHAVIOR GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:PONTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:626-449-2484
Mailing Address - Street 1:625 FAIR OAKS AVE
Mailing Address - Street 2:SUITE 390
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2630
Mailing Address - Country:US
Mailing Address - Phone:626-449-2484
Mailing Address - Fax:626-449-1107
Practice Address - Street 1:625 FAIR OAKS AVENUE
Practice Address - Street 2:SUITE 390
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030
Practice Address - Country:US
Practice Address - Phone:626-449-2484
Practice Address - Fax:626-449-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12133103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16435Medicare PIN