Healthcare Provider Details

I. General information

NPI: 1679946412
Provider Name (Legal Business Name): MAURICE JARREL PONDER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 COURT ST
LYNCHBURG VA
24504-1312
US

IV. Provider business mailing address

620 COURT ST
LYNCHBURG VA
24504-1312
US

V. Phone/Fax

Practice location:
  • Phone: 434-847-8035
  • Fax: 434-485-8877
Mailing address:
  • Phone: 434-847-8035
  • Fax: 434-485-8877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCMHC13117
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16679
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006366
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12840192-6004
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC013732
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-22948
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: