Provider Demographics
NPI:1689831034
Name:POTOCZNIAK, MICHAEL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:POTOCZNIAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 BANCROFT WAY SPC 4300
Mailing Address - Street 2:UC BERKELEY -COUNSELING AND PSYCHOLOGICAL SERVICES
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-4300
Mailing Address - Country:US
Mailing Address - Phone:510-418-0477
Mailing Address - Fax:
Practice Address - Street 1:5665 COLLEGE AVE STE 230A
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1639
Practice Address - Country:US
Practice Address - Phone:510-418-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21794103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist