Healthcare Provider Details

I. General information

NPI: 1073030011
Provider Name (Legal Business Name): SAMANTHA STAR PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E FAIRVIEW AVE APT A
SAN GABRIEL CA
91776-3039
US

IV. Provider business mailing address

8939 S SEPULVEDA BLVD STE 460
LOS ANGELES CA
90045-3653
US

V. Phone/Fax

Practice location:
  • Phone: 323-485-7715
  • Fax:
Mailing address:
  • Phone: 323-485-7715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number90672
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: