Provider Demographics
NPI:1225316391
Name:POTENTIA FAMILY THERAPY, INC.
Entity Type:Organization
Organization Name:POTENTIA FAMILY THERAPY, INC.
Other - Org Name:POTENTIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BASS-CHING
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:619-819-0283
Mailing Address - Street 1:3160 CAMINO DEL RIO S
Mailing Address - Street 2:304
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3813
Mailing Address - Country:US
Mailing Address - Phone:619-819-0283
Mailing Address - Fax:619-819-0284
Practice Address - Street 1:3160 CAMINO DEL RIO S
Practice Address - Street 2:304
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3813
Practice Address - Country:US
Practice Address - Phone:619-819-0283
Practice Address - Fax:619-819-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-23
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty