Provider Demographics
NPI:1386111698
Name:PONCE-PRIETO, LILLY
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:PONCE-PRIETO
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 1:140 IROQUOIS ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5135
Mailing Address - Country:US
Mailing Address - Phone:786-514-2643
Mailing Address - Fax:
Practice Address - Street 1:140 IROQUOIS ST
Practice Address - Street 2:
Practice Address - City:MIAMI SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33166-5135
Practice Address - Country:US
Practice Address - Phone:786-514-2643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-18-71630106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician