=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396481180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHAEL MARIEL POTTHAST PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2022
-----------------------------------------------------
Last Update Date | 05/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 559 ZOR SHRINE PL
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-2068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-580-9707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2409 PARMENTER ST APT 117
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-2687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-580-9707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------