MEDICARE: CHARLES STUART POTRYKUS MA

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	101YM0800X	Mental Health Counselor		WA

General Provider Information

NPI Number	:	1346444395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES STUART POTRYKUS MA

Provider Business Mailing Address
First Line	:	8514 HOLLY LN
Second Line	:
City	:	EDMONDS
State	:	WA
Zip	:	98026-8635
Country	:	US
Telephone Number	:	206-313-9546
Fax Number	:

Provider Business Practice Location Address
First Line	:	8514 HOLLY LN
Second Line	:
City	:	EDMONDS
State	:	WA
Zip	:	98026-8635
Country	:	US
Telephone Number	:	206-313-9546
Fax Number	:

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	01/24/2022

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