Healthcare Provider Details

I. General information

NPI: 1205008075
Provider Name (Legal Business Name): KELLI POTOCZNY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1993 SILVER KNIGHT DR
SISTERSVILLE WV
26175-9600
US

IV. Provider business mailing address

1993 SILVER KNIGHT DR
SISTERSVILLE WV
26175-9600
US

V. Phone/Fax

Practice location:
  • Phone: 304-758-2145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: