Provider Demographics
NPI:1396481180
Name:POTTHAST, RACHAEL MARIEL (PSYD)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARIEL
Last Name:POTTHAST
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:MARIEL POTTHAST
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2409 PARMENTER ST APT 117
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-2687
Mailing Address - Country:US
Mailing Address - Phone:727-580-9707
Mailing Address - Fax:
Practice Address - Street 1:559 ZOR SHRINE PL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-2068
Practice Address - Country:US
Practice Address - Phone:727-580-9707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist