Provider Demographics
NPI:1609817147
Name:POTTORF, LAURIE ANN (MA)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANN
Last Name:POTTORF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:ANN
Other - Last Name:POTTORF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4650 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3612
Mailing Address - Country:US
Mailing Address - Phone:918-712-8300
Mailing Address - Fax:
Practice Address - Street 1:5525 E 51ST ST
Practice Address - Street 2:SUITE #400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7461
Practice Address - Country:US
Practice Address - Phone:918-388-6276
Practice Address - Fax:918-388-6456
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional