Provider Demographics
NPI:1205281193
Name:PONCE, ANIEL
Entity type:Individual
Prefix:
First Name:ANIEL
Middle Name:
Last Name:PONCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8488
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-8607
Mailing Address - Country:US
Mailing Address - Phone:858-264-5858
Mailing Address - Fax:858-649-6012
Practice Address - Street 1:11650 IBERIA PL STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2431
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:858-649-6012
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical