Provider Demographics
NPI:1679875264
Name:POTJE, MARY VERONICA
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:VERONICA
Last Name:POTJE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 PETALUMA AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472
Mailing Address - Country:US
Mailing Address - Phone:707-829-2217
Mailing Address - Fax:
Practice Address - Street 1:435 PETALUMA AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-829-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist