Provider Demographics
NPI:1922292622
Name:POTENZA, ELOISE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELOISE
Middle Name:MARIE
Last Name:POTENZA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PEEL ST
Mailing Address - Street 2:
Mailing Address - City:SELKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12158-9734
Mailing Address - Country:US
Mailing Address - Phone:518-439-8218
Mailing Address - Fax:518-478-0751
Practice Address - Street 1:1311 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2905
Practice Address - Country:US
Practice Address - Phone:518-374-6263
Practice Address - Fax:518-374-1778
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016484103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist