MEDICARE: DR. IRA POTASHNER PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	019399	NY
2	103TC0700X	Clinical Psychologist	3424	CT

General Provider Information

NPI Number	:	1225341696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRA POTASHNER PSYD

Provider Business Mailing Address
First Line	:	61 S MAIN ST STE 209
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2403
Country	:	US
Telephone Number	:	646-575-5848
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 S MAIN ST STE 209
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2403
Country	:	US
Telephone Number	:	646-575-5848
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2010
Last Update Date	:	02/09/2021

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