Healthcare Provider Details

I. General information

NPI: 1073351862
Provider Name (Legal Business Name): PIVOTS POTENTIAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE # 4433
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

13606 WOODLAND HEIGHTS DR
HAGERSTOWN MD
21742-2380
US

V. Phone/Fax

Practice location:
  • Phone: 240-457-9505
  • Fax:
Mailing address:
  • Phone: 240-457-9505
  • Fax:

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: VIDA LYNNE PENN LEON
Title or Position: EXECUTIVE OFFICER
Credential: LCSW
Phone: 240-457-9505