Provider Demographics
NPI:1811334519
Name:POTTHOFF, LOIS KAY (MA)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:KAY
Last Name:POTTHOFF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24144 215TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-8647
Mailing Address - Country:US
Mailing Address - Phone:712-563-5285
Mailing Address - Fax:855-303-9139
Practice Address - Street 1:515 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1056
Practice Address - Country:US
Practice Address - Phone:712-563-5285
Practice Address - Fax:855-303-9139
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074609101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1225805799OtherGROUP TYPE 2 NPI
IA0504297Medicaid