=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336574748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOAN LOUISE PONTIUS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2013
-----------------------------------------------------
Last Update Date | 09/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 219 N DIXIE WAY SUITE135
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46637-3369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-360-3305
-----------------------------------------------------
Fax | 574-271-3740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 N DIXIE WAY SUITE135
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46637-3369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-360-3305
-----------------------------------------------------
Fax | 574-271-3740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MS. JOAN LOUISE PONTIUS
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 574-360-3305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------