Healthcare Provider Details

I. General information

NPI: 1710150875
Provider Name (Legal Business Name): POTENTIAL UNLIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 SISKIYOU BLVD SUITE 9
ASHLAND OR
97520-2125
US

IV. Provider business mailing address

PO BOX 1316
ASHLAND OR
97520-0044
US

V. Phone/Fax

Practice location:
  • Phone: 541-482-2780
  • Fax: 541-482-2780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC0060
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: SUSAN C BERRYHILL
Title or Position: CLINIC DIRECTOR
Credential: LPC
Phone: 541-482-2780