Provider Demographics
NPI:1801555727
Name:MANELA-POTZMAN, RENA BLAINE (MED, LPC, PMH-C)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:BLAINE
Last Name:MANELA-POTZMAN
Suffix:
Gender:F
Credentials:MED, LPC, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18017-9059
Mailing Address - Country:US
Mailing Address - Phone:610-349-1139
Mailing Address - Fax:
Practice Address - Street 1:5508 GRACE AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-9059
Practice Address - Country:US
Practice Address - Phone:610-349-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC014046Medicaid