Provider Demographics
NPI:1134639628
Name:POTENZA PSYCHOTHERAPY
Entity type:Organization
Organization Name:POTENZA PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTACAVOLI-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-929-1719
Mailing Address - Street 1:4021 ROLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2032
Mailing Address - Country:US
Mailing Address - Phone:253-569-5383
Mailing Address - Fax:
Practice Address - Street 1:10 E MOUNT VERNON PL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2309
Practice Address - Country:US
Practice Address - Phone:410-929-1719
Practice Address - Fax:410-929-1719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1649627480Medicaid