MEDICARE: PONMALAR ROBIN WESLEY SAMUEL

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	101YP2500X	Professional Counselor	81144	TX

General Provider Information

NPI Number	:	1982210027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PONMALAR ROBIN WESLEY SAMUEL

Provider Business Mailing Address
First Line	:	2801 COUNTRY CHURCH RD
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-4431
Country	:	US
Telephone Number	:	201-325-1703
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 COUNTRY CHURCH RD
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-4431
Country	:	US
Telephone Number	:	201-325-1703
Fax Number	:

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

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	10/15/2020

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