MEDICARE: SYDNEY VIRGINIA 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
1	235Z00000X	Speech-Language Pathologist	PCET002877	GA
2	235Z00000X	Speech-Language Pathologist	SLP011023	GA

General Provider Information

NPI Number	:	1750941555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY VIRGINIA PONCE DE LEON

Provider Business Mailing Address
First Line	:	495 WINN WAY STE 210
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1710
Country	:	US
Telephone Number	:	770-209-9826
Fax Number	:

Provider Business Practice Location Address
First Line	:	495 WINN WAY STE 210
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1710
Country	:	US
Telephone Number	:	770-209-9826
Fax Number	:

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

Provider Enumeration Date	:	06/14/2019
Last Update Date	:	12/14/2022

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Directions to “ SYDNEY VIRGINIA PONCE DE LEON ” Practice Location

Language	Start Address	Practice Location

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