=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487146791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTOMAC BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2018
-----------------------------------------------------
Last Update Date | 06/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7731 MILTON CIR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-907-6518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7731 MILTON CIR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20155-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-907-6518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST/ REPRESENTATIVE
-----------------------------------------------------
Name | DR. NYSA MARINDA PAYSOUR
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 678-907-6518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 0101254242
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------