Provider Demographics
NPI:1275626129
Name:POTHAST, MICHELLE L (MSSA LSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:POTHAST
Suffix:
Gender:F
Credentials:MSSA LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 CRANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4255 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HILLS
Practice Address - State:OH
Practice Address - Zip Code:44128
Practice Address - Country:US
Practice Address - Phone:216-521-5050
Practice Address - Fax:216-292-9721
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0600337104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker