Provider Demographics
NPI:1578236642
Name:POTTHOFF, DEREK MICHAEL (LMSW)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MICHAEL
Last Name:POTTHOFF
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 HIGHWAY 10 W
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1500
Mailing Address - Country:US
Mailing Address - Phone:712-707-9222
Mailing Address - Fax:
Practice Address - Street 1:1217 HIGHWAY 10 W
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-1500
Practice Address - Country:US
Practice Address - Phone:712-707-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA104991101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor