Healthcare Provider Details

I. General information

NPI: 1417300468
Provider Name (Legal Business Name): MATTHEW PONSFORD M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 NW MAPLE ST STE 210
ISSAQUAH WA
98027-8127
US

IV. Provider business mailing address

1740 NW MAPLE ST STE 210
ISSAQUAH WA
98027-8127
US

V. Phone/Fax

Practice location:
  • Phone: 206-719-8230
  • Fax:
Mailing address:
  • Phone: 206-719-8230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60679555
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60769223
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: