Healthcare Provider Details

I. General information

NPI: 1881798171
Provider Name (Legal Business Name): PERSONA NEURO BEHAVIOR GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVENUE SUITE 390
SOUTH PASADENA CA
91030
US

IV. Provider business mailing address

625 FAIR OAKS AVE SUITE 390
SOUTH PASADENA CA
91030-2630
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-2484
  • Fax: 626-449-1107
Mailing address:
  • Phone: 626-449-2484
  • Fax: 626-449-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY12133
License Number StateCA

VIII. Authorized Official

Name: DR. MARCEL O. PONTON
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 626-449-2484