Healthcare Provider Details

I. General information

NPI: 1255588307
Provider Name (Legal Business Name): JOHN PONDER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20430 BRIAN WAY SUITE 2
TEHACHAPI CA
93561
US

IV. Provider business mailing address

PO BOX 91
TEHACHAPI CA
93581-0091
US

V. Phone/Fax

Practice location:
  • Phone: 619-813-7154
  • Fax:
Mailing address:
  • Phone: 619-813-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY22104
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: