Healthcare Provider Details

I. General information

NPI: 1457403099
Provider Name (Legal Business Name): POTOMAC CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 HOLMES RUN PKWY STE C4
ALEXANDRIA VA
22304-2863
US

IV. Provider business mailing address

5500 HOLMES RUN PKWY SUITE C4
ALEXANDRIA VA
22304-2863
US

V. Phone/Fax

Practice location:
  • Phone: 703-379-7350
  • Fax: 703-379-7352
Mailing address:
  • Phone: 703-379-7350
  • Fax: 703-379-7352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. NATHALIE GALLET
Title or Position: VP
Credential:
Phone: 705-379-7350