Provider Demographics
NPI:1689041907
Name:POTVIN, ANNABELL ROSS (N/A)
Entity type:Individual
Prefix:
First Name:ANNABELL
Middle Name:ROSS
Last Name:POTVIN
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CREST AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-4029
Mailing Address - Country:US
Mailing Address - Phone:507-313-4129
Mailing Address - Fax:
Practice Address - Street 1:12 CREST AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-4029
Practice Address - Country:US
Practice Address - Phone:507-313-4129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XOtherSTUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM