Healthcare Provider Details

I. General information

NPI: 1508468935
Provider Name (Legal Business Name): MICHELLE POND ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 LAKE HELIX DR
LA MESA CA
91941-4434
US

IV. Provider business mailing address

5 LAKE HELIX DR
LA MESA CA
91941-4434
US

V. Phone/Fax

Practice location:
  • Phone: 619-571-1149
  • Fax:
Mailing address:
  • Phone: 619-571-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT7138
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3126905
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000027725
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: