MEDICARE: MS. MARILYN R POTTS M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PS004246L	PA

General Provider Information

NPI Number	:	1356564603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARILYN R POTTS M.ED.

Provider Business Mailing Address
First Line	:	2200 BENJAMIN FRANKLIN PKWY
Second Line	:	PARK TOWNE PLACE, EAST 105
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3601
Country	:	US
Telephone Number	:	215-963-1095
Fax Number	:	215-827-5804

Provider Business Practice Location Address
First Line	:	2200 BENJAMIN FRANKLIN PKWY
Second Line	:	PARK TOWNE PLACE, EAST 105
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3601
Country	:	US
Telephone Number	:	215-963-1095
Fax Number	:	215-827-5804

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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