Provider Demographics
NPI:1598249658
Name:POTTANAT, MARYANN J (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:J
Last Name:POTTANAT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5938
Mailing Address - Country:US
Mailing Address - Phone:617-501-2801
Mailing Address - Fax:
Practice Address - Street 1:85 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-5938
Practice Address - Country:US
Practice Address - Phone:617-501-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1136071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical