Provider Demographics
NPI:1124856471
Name:COTA PONCE, CYNTHIA J
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:COTA PONCE
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 1:617 3RD AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5717
Mailing Address - Country:US
Mailing Address - Phone:619-822-3515
Mailing Address - Fax:
Practice Address - Street 1:9685 VIA EXCELENCIA STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-7500
Practice Address - Country:US
Practice Address - Phone:619-369-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-325489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician