Basic Information
| Provider Information | |||||||||
| NPI: | 1609957299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | PONNEARY | ||||||||
| MiddleName: | KE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2008 N. GAREY AVE., | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917679036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2008 N. GAREY AVE., | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096236131 | ||||||||
| FaxNumber: | 3232238380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 09/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 75017 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 101YM0800X | 75017 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.