Healthcare Provider Details

I. General information

NPI: 1437732880
Provider Name (Legal Business Name): SELENA PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2259 MYRTLE AVE
EUREKA CA
95501-3325
US

IV. Provider business mailing address

2259 MYRTLE AVE
EUREKA CA
95501-3325
US

V. Phone/Fax

Practice location:
  • Phone: 707-444-8293
  • Fax:
Mailing address:
  • Phone: 707-444-8293
  • Fax: 707-444-8298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: