Provider Demographics
NPI:1427039528
Name:POTOCKI RATAJCZAK, EILEEN R (PHD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:R
Last Name:POTOCKI RATAJCZAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:EILEEN
Other - Middle Name:R
Other - Last Name:POTOCKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:10 N GREENE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1524
Mailing Address - Country:US
Mailing Address - Phone:410-605-7000
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R89662Medicare UPIN