Provider Demographics
NPI:1285943985
Name:PONDER, DIANE E (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:PONDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9830 NE CASCADES PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-6832
Mailing Address - Country:US
Mailing Address - Phone:503-239-8101
Mailing Address - Fax:503-239-8106
Practice Address - Street 1:9830 NE CASCADES PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-6832
Practice Address - Country:US
Practice Address - Phone:503-239-8101
Practice Address - Fax:503-239-8106
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical