Provider Demographics
NPI:1588186464
Name:POTARAZU, CHELSEA
Entity Type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:POTARAZU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 83335
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20883-3335
Mailing Address - Country:US
Mailing Address - Phone:410-940-9392
Mailing Address - Fax:
Practice Address - Street 1:510 MCCORMICK DR STE U-V
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3283
Practice Address - Country:US
Practice Address - Phone:410-595-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001541103K00000X
106E00000X
MDLBA741103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst