Provider Demographics
NPI:1346444395
Name:POTRYKUS, CHARLES STUART (MA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STUART
Last Name:POTRYKUS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8514 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-8635
Mailing Address - Country:US
Mailing Address - Phone:206-313-9546
Mailing Address - Fax:
Practice Address - Street 1:8514 HOLLY LN
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8635
Practice Address - Country:US
Practice Address - Phone:206-313-9546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health