=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003456435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EILEEN A POTAMOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2020
-----------------------------------------------------
Last Update Date | 01/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 W 13TH ST PH A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-750-0776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1108 CYPRESS TRACE DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-1619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-750-0776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number | 000434-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------