Healthcare Provider Details

I. General information

NPI: 1558701961
Provider Name (Legal Business Name): MS. KATHRYN SUZANNE POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2013
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13115 KENTLAND LN
MORENO VALLEY CA
92553-4283
US

IV. Provider business mailing address

13115 KENTLAND LN
MORENO VALLEY CA
92553-4283
US

V. Phone/Fax

Practice location:
  • Phone: 909-762-2648
  • Fax:
Mailing address:
  • Phone: 909-762-2648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number62984
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW82169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: