MEDICARE: YOLANDA AMBER PONDER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	30867	ID
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	33404	ID

General Provider Information

NPI Number	:	1568743359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YOLANDA AMBER PONDER LCSW

Provider Business Mailing Address
First Line	:	310 CLEVELAND BLVD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-3624
Country	:	US
Telephone Number	:	208-779-5008
Fax Number	:	208-779-5009

Provider Business Practice Location Address
First Line	:	310 CLEVELAND BLVD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-3624
Country	:	US
Telephone Number	:	208-954-0597
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2011
Last Update Date	:	02/03/2021

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