Healthcare Provider Details

I. General information

NPI: 1205469475
Provider Name (Legal Business Name): UNCAGED POTENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OLYMPIC PL STE 900
TOWSON MD
21204-4113
US

IV. Provider business mailing address

703 DALE AVE
BALTIMORE MD
21206-1308
US

V. Phone/Fax

Practice location:
  • Phone: 201-920-6787
  • Fax:
Mailing address:
  • Phone: 201-920-6787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY AVILES
Title or Position: THERAPIST
Credential:
Phone: 201-920-6787