Provider Demographics
NPI:1588791180
Name:PONCHALEK, KARL RICHARD (LISW)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:RICHARD
Last Name:PONCHALEK
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIV OF NM
Mailing Address - Street 2:MSC06 UMN STUDENT HEALTH CENTER
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-3136
Mailing Address - Fax:505-277-5668
Practice Address - Street 1:1 UNIV OF NM
Practice Address - Street 2:MSC06 UMN STUDENT HEALTH CENTER
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-277-3136
Practice Address - Fax:505-277-5668
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI05319104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker