Provider Demographics
NPI:1871641324
Name:POTTHAST, ALICE FAYE (M ED, LMFT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:FAYE
Last Name:POTTHAST
Suffix:
Gender:F
Credentials:M ED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 N 2600 E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-0191
Mailing Address - Country:US
Mailing Address - Phone:208-736-3808
Mailing Address - Fax:
Practice Address - Street 1:647 FILER AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4008
Practice Address - Country:US
Practice Address - Phone:208-737-9999
Practice Address - Fax:208-736-4400
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-2899106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010156782OtherREGENCE BLUE SHIELD OF ID
ID000010156783OtherREGENCE BLUE SHIELD OF ID