Basic Information
| Provider Information | |||||||||
| NPI: | 1255931242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FULL POTENTIAL THERAPY, P LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 STEARNS ST | ||||||||
| Address2: | |||||||||
| City: | SWAMPSCOTT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019071428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179906887 | ||||||||
| FaxNumber: | 6178198063 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 ESSEX ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019703452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179906887 | ||||||||
| FaxNumber: | 6178198063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIOUX | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | WILD | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH THERAPIST/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6179906887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.