Healthcare Provider Details

I. General information

NPI: 1578640629
Provider Name (Legal Business Name): JO POTESTIVO LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. JOANNA POTESTIVO

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

800 POLY PL
BROOKLYN NY
11209-7104
US

V. Phone/Fax

Practice location:
  • Phone: 718-836-6600
  • Fax:
Mailing address:
  • Phone: 712-702-2028
  • Fax: 718-630-2935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR068806
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: