Provider Demographics
NPI:1710128632
Name:POTASH, JOHN L (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:POTASH
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 OAK LODGE RD
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4765
Mailing Address - Country:US
Mailing Address - Phone:410-960-7744
Mailing Address - Fax:
Practice Address - Street 1:6106 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-1830
Practice Address - Country:US
Practice Address - Phone:410-960-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD129231041C0700X
CT0061541041C0700X
NY0731801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD166644Medicare PIN