Provider Demographics
NPI:1972216869
Name:RELEASE AND RENEW MENTAL WELLNESS CLINIC
Entity type:Organization
Organization Name:RELEASE AND RENEW MENTAL WELLNESS CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-PMH
Authorized Official - Phone:443-745-8620
Mailing Address - Street 1:1301 YORK RD STE 800
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6011
Mailing Address - Country:US
Mailing Address - Phone:410-376-8728
Mailing Address - Fax:410-862-3774
Practice Address - Street 1:1301 YORK RD STE 800
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6011
Practice Address - Country:US
Practice Address - Phone:410-376-8728
Practice Address - Fax:410-862-3774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health