Provider Demographics
NPI:1629845672
Name:POTOCNIK MEDINA, KATHLEEN ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:POTOCNIK MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MADISON SQ W FL 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1629
Mailing Address - Country:US
Mailing Address - Phone:917-310-0512
Mailing Address - Fax:
Practice Address - Street 1:16 MADISON SQ W FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1629
Practice Address - Country:US
Practice Address - Phone:917-562-2921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0965671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical