Provider Demographics
NPI:1588994107
Name:PONICHTER, BETHANY
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PONICHTER
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 1:343 S MAIN ST STE 209B
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2137
Mailing Address - Country:US
Mailing Address - Phone:734-418-9180
Mailing Address - Fax:
Practice Address - Street 1:343 S MAIN ST STE 209B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2137
Practice Address - Country:US
Practice Address - Phone:248-259-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16241174400000X
MI68010983511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist