Provider Demographics
NPI:1235619677
Name:POTATO, GENEVIEVE
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:POTATO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13503 DURANGO PASS DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-1781
Mailing Address - Country:US
Mailing Address - Phone:989-305-1363
Mailing Address - Fax:
Practice Address - Street 1:2750 MILLER RANCH RD
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584
Practice Address - Country:US
Practice Address - Phone:713-770-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1226383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist