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NPI Code Detail

MEDICARE: CRYSTAL NICOLE PONCE DE LEON

MEDICARE: CRYSTAL NICOLE PONCE DE LEON
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
1104100000XSocial Worker6802090292MI

General Provider Information

NPI Number : 1184180606
Entity Type Code : Individual
Provider Name (Legal Business Name) : CRYSTAL NICOLE PONCE DE LEON
Provider Business Mailing Address
First Line : 5111 AUTO CLUB DR STE 112
Second Line :
City : DEARBORN
State : MI
Zip : 48126-2684
Country : US
Telephone Number : 248-276-8000
Fax Number :
Provider Business Practice Location Address
First Line : 1270 DORIS RD
Second Line :
City : AUBURN HILLS
State : MI
Zip : 48326-2617
Country : US
Telephone Number : 248-276-8000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/20/2019
Last Update Date : 02/03/2026

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Directions to “ CRYSTAL NICOLE PONCE DE LEON ” Practice Location

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