Provider Demographics
NPI:1053562793
Name:POTTHAST, SUSAN LEE (LMHC,LMT)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:POTTHAST
Suffix:
Gender:F
Credentials:LMHC,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14542 61ST AVE.
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:IA
Mailing Address - Zip Code:52726-9592
Mailing Address - Country:US
Mailing Address - Phone:563-381-4649
Mailing Address - Fax:
Practice Address - Street 1:14542 61ST AVE.
Practice Address - Street 2:
Practice Address - City:BLUE GRASS
Practice Address - State:IA
Practice Address - Zip Code:52726-9592
Practice Address - Country:US
Practice Address - Phone:563-381-4649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health