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General NPI Number Information
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NPI Number | 1134639628
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Entity Type | Organization
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Legal Business Name | POTENZA PSYCHOTHERAPY
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Dates
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Enumeration Date | 10/10/2017
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Last Update Date | 10/10/2017
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Provider Practice Location Address
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Address Line | 10 E MOUNT VERNON PL
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City | BALTIMORE
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State | MD
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Zip | 21202-2309
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Country | US
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Telephone | 410-929-1719
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Fax | 410-929-1719
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Provider Business Mailing Address
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Address Line | 4021 ROLAND AVE
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City | BALTIMORE
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State | MD
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Zip | 21211-2032
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Country | US
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Telephone | 253-569-5383
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JESSICA BUTTACAVOLI-SMITH
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Credential | PHD
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Telephone | 410-929-1719
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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