Provider Demographics
NPI:1205469475
Name:UNCAGED POTENTIAL
Entity type:Organization
Organization Name:UNCAGED POTENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-920-6787
Mailing Address - Street 1:703 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-1308
Mailing Address - Country:US
Mailing Address - Phone:201-920-6787
Mailing Address - Fax:
Practice Address - Street 1:1 OLYMPIC PL STE 900
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4113
Practice Address - Country:US
Practice Address - Phone:201-920-6787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health