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General NPI Number Information
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NPI Number | 1225316391
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Entity Type | Organization
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Legal Business Name | POTENTIA FAMILY THERAPY, INC.
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Dates
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Enumeration Date | 07/23/2011
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Last Update Date | 07/23/2011
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Provider Practice Location Address
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Address Line | 3160 CAMINO DEL RIO S 304
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City | SAN DIEGO
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State | CA
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Zip | 92108-3813
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Country | US
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Telephone | 619-819-0283
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Fax | 619-819-0284
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Provider Business Mailing Address
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Address Line | 3160 CAMINO DEL RIO S 304
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City | SAN DIEGO
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State | CA
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Zip | 92108-3813
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Country | US
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Telephone | 619-819-0283
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Fax | 619-819-0284
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Authorized Official
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Title or Position | OWNER AND DIRECTOR
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Name | MRS. REBECCA D BASS-CHING
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Credential | LMFT
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Telephone | 619-819-0283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 44584
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License Number State | CA
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