Healthcare Provider Details

I. General information

NPI: 1861910887
Provider Name (Legal Business Name): ERNESTO D PONCE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24302 NORTHERN BLVD
LITTLE NECK NY
11362-1150
US

IV. Provider business mailing address

145 CARPENTER AVE APT 5
SEA CLIFF NY
11579-1338
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-6200
  • Fax:
Mailing address:
  • Phone: 516-313-3076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number101269-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: