Healthcare Provider Details

I. General information

NPI: 1447833561
Provider Name (Legal Business Name): KATINA MICHELLE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS
PASADENA CA
91103
US

IV. Provider business mailing address

3175 MEYERS ST
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 951-358-3071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number161066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: