=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710173802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTENTIALS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 09/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 39TH ST PIER 39
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-2499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-325-2398
-----------------------------------------------------
Fax | 503-325-5932
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 39TH ST PIER 39
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-2499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-325-2398
-----------------------------------------------------
Fax | 503-325-5932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/THERAPIST
-----------------------------------------------------
Name | MS. DANA S DEDOLPH
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 503-325-2398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | C1489
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------