Provider Demographics
NPI:1174906630
Name:PONCE, GUADALUPE
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:PONCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1263 LOWNES PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4214
Mailing Address - Country:US
Mailing Address - Phone:909-455-7998
Mailing Address - Fax:
Practice Address - Street 1:17727 E CYPRESS ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-2634
Practice Address - Country:US
Practice Address - Phone:626-967-2677
Practice Address - Fax:626-858-4923
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5091083101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)