Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | 20042019A | IN |
N | 103TC0700X | Clinical Psychologist | 20042019A | IN |
N | 102L00000X | Psychologist | 2781 | WI |
N | 103T00000X | Psychologist | 2781 | WI |
N | 103G00000X | Clinical Psychologist | 20042019A | IN |
N | 103TC0700X | Clinical Psychologist | 20042019A | IN |
Y | 103G00000X | Clinical Psychologist | 2781 | WI |
Y | 103TC0700X | Clinical Psychologist | 2781 | WI |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 20042019A | IN |
N | 103TF0200X | Forensic Psychologist | 20042019A | IN |
NPI | 1114941572 |
---|---|
Provider Name | Dr. Stephen Pongonis |
First Address | Eau Claire, WI 54702-1510 |
Second Address | Eau Claire, WI 54703-5222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 15/09/2020 |