Provider Demographics
NPI:1548369184
Name:POTHEN, MINI
Entity type:Individual
Prefix:MS
First Name:MINI
Middle Name:
Last Name:POTHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16215 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1911
Mailing Address - Country:US
Mailing Address - Phone:718-591-7054
Mailing Address - Fax:
Practice Address - Street 1:7603 113TH ST
Practice Address - Street 2:SUITE M6
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6530
Practice Address - Country:US
Practice Address - Phone:718-268-1100
Practice Address - Fax:718-263-6418
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016036103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02797560Medicaid
NY02797560Medicaid