Healthcare Provider Details

I. General information

NPI: 1710322318
Provider Name (Legal Business Name): HOLLY POTTER L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 KINGS HWY
GROTON CT
06340-3436
US

IV. Provider business mailing address

15 MELLOW CT # 1
PAWCATUCK CT
06379-7921
US

V. Phone/Fax

Practice location:
  • Phone: 860-861-8978
  • Fax:
Mailing address:
  • Phone: 860-861-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number005385
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: