Healthcare Provider Details

I. General information

NPI: 1184789133
Provider Name (Legal Business Name): PATRICIA L PONCE DPT,OSC,SCS,ATC,CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2328 W JOPPA RD SUITE 300
LUTHERVILLE MD
21093-4612
US

IV. Provider business mailing address

6905 YALE RD
MIDDLE RIVER MD
21220-1050
US

V. Phone/Fax

Practice location:
  • Phone: 410-938-8660
  • Fax: 410-938-8664
Mailing address:
  • Phone: 410-335-9883
  • Fax: 410-938-8664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number21138
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: