Provider Demographics
NPI:1881704468
Name:POTVIN, KIM MARIE (MA LADC)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:POTVIN
Suffix:
Gender:F
Credentials:MA LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18 BANK AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-2218
Mailing Address - Country:US
Mailing Address - Phone:802-295-9363
Mailing Address - Fax:802-296-6389
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:MAILBOX 116E
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:802-296-6389
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000356170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT000356OtherLICENSED ALCOHOL AND DRUG