Healthcare Provider Details

I. General information

NPI: 1033384227
Provider Name (Legal Business Name): THERESE PONCY M.S.W., C.S.W.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 NW WALL ST.
BEND OR
97701-7638
US

IV. Provider business mailing address

2577 NE COURTNEY DR
BEND OR
97701-7638
US

V. Phone/Fax

Practice location:
  • Phone: 541-330-4681
  • Fax: 541-388-6617
Mailing address:
  • Phone: 541-322-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA2808
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: