Healthcare Provider Details

I. General information

NPI: 1699679688
Provider Name (Legal Business Name): UNLEASHED POTENTIAL PSYCHOTHERAPY LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MELWOOD DR
COMMACK NY
11725-5610
US

IV. Provider business mailing address

169 COMMACK RD # 1015
COMMACK NY
11725-3442
US

V. Phone/Fax

Practice location:
  • Phone: 631-432-8897
  • Fax:
Mailing address:
  • Phone: 631-432-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JESSICA ANN REBELO
Title or Position: PRESIDENT
Credential: LCSW
Phone: 631-432-8897