Healthcare Provider Details

I. General information

NPI: 1811334519
Provider Name (Legal Business Name): LOIS KAY POTTHOFF MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PACIFIC AVE
AUDUBON IA
50025-1056
US

IV. Provider business mailing address

24144 215TH ST
CARROLL IA
51401-8647
US

V. Phone/Fax

Practice location:
  • Phone: 712-563-5285
  • Fax: 855-303-9139
Mailing address:
  • Phone: 712-563-5285
  • Fax: 855-303-9139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number074609
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1225805799
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerGROUP TYPE 2 NPI
# 2
Identifier0504297
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: