Healthcare Provider Details

I. General information

NPI: 1306922687
Provider Name (Legal Business Name): PHYLLIS POTTER CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1553 SACRAMENTO ST
BERKELEY CA
94702-1206
US

IV. Provider business mailing address

1553 SACRAMENTO ST
BERKELEY CA
94702-1206
US

V. Phone/Fax

Practice location:
  • Phone: 510-295-9605
  • Fax: 510-527-8175
Mailing address:
  • Phone: 510-295-9605
  • Fax: 510-527-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: