Provider Demographics
NPI:1104136308
Name:PONCE, ELEANOR (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:ELEANOR
Middle Name:
Last Name:PONCE
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 PETERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4801
Mailing Address - Country:US
Mailing Address - Phone:631-647-7896
Mailing Address - Fax:
Practice Address - Street 1:795 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2336
Practice Address - Country:US
Practice Address - Phone:631-434-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5540369411041S0200X
NYR035920-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical