Healthcare Provider Details

I. General information

NPI: 1376403196
Provider Name (Legal Business Name): ELISE MARGARITA PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

710 S MYRTLE AVE # 145
MONROVIA CA
91016-3423
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number160160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: