Provider Demographics
NPI:1750597878
Name:POTTS, KATHLEEN MARY (LMSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:POTTS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 HUGUENOT DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-6103
Mailing Address - Country:US
Mailing Address - Phone:631-399-1913
Mailing Address - Fax:
Practice Address - Street 1:35 LONGWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2045
Practice Address - Country:US
Practice Address - Phone:631-924-0008
Practice Address - Fax:631-924-4602
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033753-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool