Provider Demographics
NPI:1073351862
Name:PIVOTS POTENTIAL LLC
Entity type:Organization
Organization Name:PIVOTS POTENTIAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VIDA LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN LEON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:240-457-9505
Mailing Address - Street 1:1401 HAVEN RD APT B12
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-3097
Mailing Address - Country:US
Mailing Address - Phone:240-457-9505
Mailing Address - Fax:
Practice Address - Street 1:1209 MOUNTAIN ROAD PL NE # 4433
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7845
Practice Address - Country:US
Practice Address - Phone:240-457-9505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty