Provider Demographics
NPI:1811460702
Name:POTAZNICK, MALLORIE (LMHC)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:POTAZNICK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4004
Mailing Address - Country:US
Mailing Address - Phone:561-536-3980
Mailing Address - Fax:
Practice Address - Street 1:9732 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4004
Practice Address - Country:US
Practice Address - Phone:561-536-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16595101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health