Healthcare Provider Details

I. General information

NPI: 1336574748
Provider Name (Legal Business Name): JOAN LOUISE PONTIUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 N DIXIE WAY SUITE135
SOUTH BEND IN
46637-3369
US

IV. Provider business mailing address

219 N DIXIE WAY SUITE135
SOUTH BEND IN
46637-3369
US

V. Phone/Fax

Practice location:
  • Phone: 574-360-3305
  • Fax: 574-271-3740
Mailing address:
  • Phone: 574-360-3305
  • Fax: 574-271-3740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: MS. JOAN LOUISE PONTIUS
Title or Position: THERAPIST
Credential: LMHC
Phone: 574-360-3305