Provider Demographics
NPI:1366097594
Name:PONCE, LEISE MONTEBON (OTR/L)
Entity type:Individual
Prefix:
First Name:LEISE
Middle Name:MONTEBON
Last Name:PONCE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 CASTLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4917
Mailing Address - Country:US
Mailing Address - Phone:443-983-2898
Mailing Address - Fax:
Practice Address - Street 1:6116 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-1927
Practice Address - Country:US
Practice Address - Phone:410-426-1424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist