Healthcare Provider Details

I. General information

NPI: 1033724943
Provider Name (Legal Business Name): NATHANIEL EDISON PONDER LMSW, CCS, CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50430 SCHOOL HOUSE RD
CANTON MI
48187-5910
US

IV. Provider business mailing address

50430 SCHOOL HOUSE RD
CANTON MI
48187-5910
US

V. Phone/Fax

Practice location:
  • Phone: 734-495-1722
  • Fax:
Mailing address:
  • Phone: 734-495-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801117080
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2-01605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: