Healthcare Provider Details

I. General information

NPI: 1609817147
Provider Name (Legal Business Name): LAURIE ANN POTTORF MA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MISS LAURIE ANN POTTORF

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 E 51ST ST SUITE #400
TULSA OK
74135-7461
US

IV. Provider business mailing address

4650 E 24TH ST
TULSA OK
74114-3612
US

V. Phone/Fax

Practice location:
  • Phone: 918-388-6276
  • Fax: 918-388-6456
Mailing address:
  • Phone: 918-712-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1268
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: