Provider Demographics
NPI:1497984892
Name:POTOMAC PSYCHOLOGICAL CENTER, LLC
Entity Type:Organization
Organization Name:POTOMAC PSYCHOLOGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTILE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:703-858-7838
Mailing Address - Street 1:20925 PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3403
Mailing Address - Country:US
Mailing Address - Phone:703-858-7838
Mailing Address - Fax:703-858-9697
Practice Address - Street 1:20925 PROFESSIONAL PLZ
Practice Address - Street 2:SUITE 230
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3403
Practice Address - Country:US
Practice Address - Phone:703-858-7838
Practice Address - Fax:703-858-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003403101YP2500X
VA0810003656103TC0700X
VA09040048631041C0700X
VA01012310512084P0800X
VA01012415322084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty