Healthcare Provider Details

I. General information

NPI: 1841761855
Provider Name (Legal Business Name): FAITH POTOESKI M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5980 RADIO STATION RD
LA PLATA MD
20646-3337
US

IV. Provider business mailing address

5140 MARBURY RUN RD
MARBURY MD
20658-2203
US

V. Phone/Fax

Practice location:
  • Phone: 301-932-6610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number07914
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: