Healthcare Provider Details

I. General information

NPI: 1275626129
Provider Name (Legal Business Name): MICHELLE L POTHAST MSSA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 NORTHFIELD RD
HIGHLAND HILLS OH
44128
US

IV. Provider business mailing address

1217 CRANFORD AVE
LAKEWOOD OH
44107
US

V. Phone/Fax

Practice location:
  • Phone: 216-521-5050
  • Fax: 216-292-9721
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS0600337
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: