Healthcare Provider Details

I. General information

NPI: 1073845145
Provider Name (Legal Business Name): PEGGY SANDERFORD PONDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2117 UNIVERSITY BLVD
BIRMINGHAM AL
35233-3107
US

IV. Provider business mailing address

4917 CLAIRMONT AVE S
BIRMINGHAM AL
35222-4420
US

V. Phone/Fax

Practice location:
  • Phone: 205-585-1713
  • Fax:
Mailing address:
  • Phone: 205-585-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number11290
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number64
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: