Provider Demographics
NPI:1528331303
Name:PONCE, MALLORY SYLVIA
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SYLVIA
Last Name: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 1:1116 DOVE BROOK DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-2701
Mailing Address - Country:US
Mailing Address - Phone:972-965-0823
Mailing Address - Fax:
Practice Address - Street 1:1116 DOVE BROOK DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-2701
Practice Address - Country:US
Practice Address - Phone:972-965-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1215131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN