Provider Demographics
NPI:1295494805
Name:POTWARDOWSKI, GRACE A
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:POTWARDOWSKI
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 1:382 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1379
Mailing Address - Country:US
Mailing Address - Phone:203-250-9663
Mailing Address - Fax:203-250-9663
Practice Address - Street 1:308 RACEBROOK ROAD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-0647
Practice Address - Country:US
Practice Address - Phone:203-920-1885
Practice Address - Fax:203-920-1881
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1085235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist