| Doctor Name: | DR. CAROL MARCIA POTRUCH |
| NPI Number: | 1003992611 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCSW, PHD |
| License Number: | R040274-1 |
| Business Practice Address: | 1527 Franklin Ave Suite 203 Mineola, NY - 115014827 |
| Business Phone Number: | 5163171493 |
| Business Fax Number: | 2127440696 |
| Mailing Address: | 220 E 67th St, NEW YORK |
| State: | NY |
| Postal Code: | 100216255 |
| Phone Number: | 5163171493 |
| Fax Number: | 2127440696 |
| NPI Enumeration Date: | 10/27/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | R040274-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |