Provider Demographics
NPI:1467955294
Name:POTTS, KATHRYN BLAKE (MS-SLP, CF)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BLAKE
Last Name:POTTS
Suffix:
Gender:F
Credentials:MS-SLP, CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 HANOVER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4049
Mailing Address - Country:US
Mailing Address - Phone:804-822-6169
Mailing Address - Fax:
Practice Address - Street 1:6800 LUCY CORR CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6657
Practice Address - Country:US
Practice Address - Phone:804-748-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22020087256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA22020087256OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS