Provider Demographics
NPI:1003456435
Name:POTAMOS, EILEEN A
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:A
Last Name:POTAMOS
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 1:1108 CYPRESS TRACE DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1619
Mailing Address - Country:US
Mailing Address - Phone:917-750-0776
Mailing Address - Fax:
Practice Address - Street 1:60 W 13TH ST PH A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7915
Practice Address - Country:US
Practice Address - Phone:917-750-0776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000434-1102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst