Healthcare Provider Details

I. General information

NPI: 1003746983
Provider Name (Legal Business Name): GEORGIA POTTER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 BROADWAY RM 1510
NEW YORK NY
10018-3368
US

IV. Provider business mailing address

1430 BROADWAY RM 1510
NEW YORK NY
10018-3368
US

V. Phone/Fax

Practice location:
  • Phone: 347-786-9802
  • Fax:
Mailing address:
  • Phone: 347-786-9802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP138062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: