Provider Demographics
NPI:1154754513
Name:PONCE, DOMITILO III (LMSW)
Entity type:Individual
Prefix:MR
First Name:DOMITILO
Middle Name:
Last Name:PONCE
Suffix:III
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15003 PEARCE LN
Mailing Address - Street 2:
Mailing Address - City:DEL VALLE
Mailing Address - State:TX
Mailing Address - Zip Code:78617-5763
Mailing Address - Country:US
Mailing Address - Phone:512-739-1710
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker