=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427763440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTOMAC PSYCHOLOGICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2023
-----------------------------------------------------
Last Update Date | 01/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 COURTHOUSE SQ STE 216
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-0399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-244-9685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60752
-----------------------------------------------------
City | POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20859-0752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-244-9685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GENINE SWANZEY-MAHON
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 301-244-9685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------