Healthcare Provider Details

I. General information

NPI: 1497984892
Provider Name (Legal Business Name): POTOMAC PSYCHOLOGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20925 PROFESSIONAL PLZ SUITE 230
ASHBURN VA
20147-3403
US

IV. Provider business mailing address

20925 PROFESSIONAL PLZ SUITE 230
ASHBURN VA
20147-3403
US

V. Phone/Fax

Practice location:
  • Phone: 703-858-7838
  • Fax: 703-858-9697
Mailing address:
  • Phone: 703-858-7838
  • Fax: 703-858-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003403
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003656
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904004863
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101231051
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101241532
License Number StateVA

VIII. Authorized Official

Name: MR. NICK GENTILE
Title or Position: PRESIDENT
Credential: LPC
Phone: 703-858-7838