Provider Demographics
NPI:1871372581
Name:PONCE, EDWARD H SR
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:PONCE
Suffix:SR
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 1:29631 SW 142ND CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3006
Mailing Address - Country:US
Mailing Address - Phone:786-417-6989
Mailing Address - Fax:
Practice Address - Street 1:29631 SW 142ND CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3006
Practice Address - Country:US
Practice Address - Phone:786-417-6989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-296915106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty