MEDICARE: PAOLA PONCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	178.021659	IL

General Provider Information

NPI Number	:	1053103283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAOLA PONCE

Provider Business Mailing Address
First Line	:	4427 S TROY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2821
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3528 S HERMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-1217
Country	:	US
Telephone Number	:	872-218-8613
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2025
Last Update Date	:	05/22/2025

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Directions to “ PAOLA PONCE ” Practice Location

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