Basic Information
| Provider Information | |||||||||
| NPI: | 1043878127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTENCIANO | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | ALMERO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 N JOHNSON AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920201651 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 MISSION AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920587110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607212781 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2019 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.