Provider Demographics
NPI:1700022399
Name:POTOCZNIAK, DANIEL JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
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 1:404 GRASSMERE AVE
Mailing Address - Street 2:
Mailing Address - City:INTERLAKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4313
Mailing Address - Country:US
Mailing Address - Phone:215-817-8738
Mailing Address - Fax:215-554-6966
Practice Address - Street 1:1985 STATE ROUTE 34 STE A3
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9101
Practice Address - Country:US
Practice Address - Phone:215-384-8624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-02
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016537103T00000X
NJ35SI00594800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist