Healthcare Provider Details

I. General information

NPI: 1225754831
Provider Name (Legal Business Name): UNCAGED POTENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 05/09/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 DALE AVE
BALTIMORE MD
21206
US

IV. Provider business mailing address

703 DALE AVE
BALTIMORE MD
21206
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-1101
  • Fax: 410-522-1181
Mailing address:
  • Phone: 410-929-1101
  • Fax: 410-522-1181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY AVILES
Title or Position: OWNER
Credential:
Phone: 410-929-1101