Provider Demographics
NPI:1710173802
Name:POTENTIALS, LLC
Entity Type:Organization
Organization Name:POTENTIALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:503-325-2398
Mailing Address - Street 1:100 39TH ST PIER 39
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2499
Mailing Address - Country:US
Mailing Address - Phone:503-325-2398
Mailing Address - Fax:503-325-5932
Practice Address - Street 1:100 39TH ST PIER 39
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2499
Practice Address - Country:US
Practice Address - Phone:503-325-2398
Practice Address - Fax:503-325-5932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1489251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health