Provider Demographics
NPI:1316642895
Name:PONS CARRALERO, LAURA M
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:PONS CARRALERO
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 1:4190 SAN MARINO BLVD APT 108
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-7721
Mailing Address - Country:US
Mailing Address - Phone:201-870-8897
Mailing Address - Fax:
Practice Address - Street 1:4190 SAN MARINO BLVD APT 108
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-7721
Practice Address - Country:US
Practice Address - Phone:201-870-8897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-257794106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician