Provider Demographics
NPI:1528042223
Name:POTTEBAUM, RANDALL R
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:POTTEBAUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-993-6450
Mailing Address - Fax:952-993-0300
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:PARK NICOLLET CLINIC BURNSVILLE
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8608
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist