Healthcare Provider Details

I. General information

NPI: 1871999797
Provider Name (Legal Business Name): MARIA IRENE PONCE MSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 ZELZAH AVE
NORTHRIDGE CA
91325-2003
US

IV. Provider business mailing address

9650 ZELZAH AVE
NORTHRIDGE CA
91325-2003
US

V. Phone/Fax

Practice location:
  • Phone: 818-993-9311
  • Fax:
Mailing address:
  • Phone: 818-993-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number68193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: