Healthcare Provider Details

I. General information

NPI: 1912740481
Provider Name (Legal Business Name): CHRISTOPHER PONCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E FOOTHILL BLVD
PASADENA CA
91107-3439
US

IV. Provider business mailing address

180 VIA VERDE STE 200
SAN DIMAS CA
91773-3993
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax:
Mailing address:
  • Phone: 909-599-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number129803
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: