Provider Demographics
NPI:1811550908
Name:POTZ, AUDRA (LMFT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:POTZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 VAN NUYS BLVD STE 406
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-5743
Mailing Address - Country:US
Mailing Address - Phone:323-539-3552
Mailing Address - Fax:
Practice Address - Street 1:4419 VAN NUYS BLVD STE 406
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-5743
Practice Address - Country:US
Practice Address - Phone:323-539-3552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist