Provider Demographics
NPI:1417104118
Name:POTAPENKO, ELIZAVETA (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZAVETA
Middle Name:
Last Name:POTAPENKO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:KHALLIEV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:2111 DICKSON DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-4796
Mailing Address - Country:US
Mailing Address - Phone:404-989-0850
Mailing Address - Fax:
Practice Address - Street 1:2111 DICKSON DR
Practice Address - Street 2:SUITE 10
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-4796
Practice Address - Country:US
Practice Address - Phone:404-989-0850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36269103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical