MEDICARE: DIANE E PONDER LCSW

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	1041C0700X	Clinical Social Worker	1294	OR

General Provider Information

NPI Number	:	1285943985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE E PONDER LCSW

Provider Business Mailing Address
First Line	:	9830 NE CASCADES PKWY
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97220-6832
Country	:	US
Telephone Number	:	503-239-8101
Fax Number	:	503-239-8106

Provider Business Practice Location Address
First Line	:	9830 NE CASCADES PKWY
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97220-6832
Country	:	US
Telephone Number	:	503-239-8101
Fax Number	:	503-239-8106

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

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	05/09/2011

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Directions to “ DIANE E PONDER LCSW” Practice Location

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