MEDICARE: GRACIELA PONCE LPCC

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	CMH0204121	NM
2	101YP2500X	Professional Counselor	CTB-2024-0609	NM

General Provider Information

NPI Number	:	1205545662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACIELA PONCE LPCC

Provider Business Mailing Address
First Line	:	385 CALLE DE ALEGRA STE A
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3423
Country	:	US
Telephone Number	:	575-526-1105
Fax Number	:	575-524-4266

Provider Business Practice Location Address
First Line	:	18420 S HIGHWAY 28
Second Line	:
City	:	LA MESA
State	:	NM
Zip	:	88044-9605
Country	:	US
Telephone Number	:	575-233-3830
Fax Number	:	575-233-4542

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

Provider Enumeration Date	:	11/15/2022
Last Update Date	:	10/29/2024

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