Provider Demographics
NPI:1831231901
Name:POTKIN, MARTY ANN (LMFT)
Entity type:Individual
Prefix:MS
First Name:MARTY
Middle Name:ANN
Last Name:POTKIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:ANN
Other - Last Name:ODOU-POTKIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:2715 PORTER ST
Mailing Address - Street 2:STE. #205
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2458
Mailing Address - Country:US
Mailing Address - Phone:831-345-4885
Mailing Address - Fax:
Practice Address - Street 1:2715 PORTER ST
Practice Address - Street 2:STE. #205
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2458
Practice Address - Country:US
Practice Address - Phone:831-345-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist