Provider Demographics
NPI:1881619229
Name:POTTEBAUM, SHEILA MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:MARIE
Last Name:POTTEBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:939 OFFICE PARK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2505
Mailing Address - Country:US
Mailing Address - Phone:515-226-2508
Mailing Address - Fax:515-440-3388
Practice Address - Street 1:939 OFFICE PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2505
Practice Address - Country:US
Practice Address - Phone:515-226-2508
Practice Address - Fax:515-440-3388
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA42105384450265A015OtherTRIWEST
IA0014316Medicaid
IA01431OtherWELLMARK BLUE CROSS
IA18669OtherMIDLANDS CHOICE
IA01431OtherWELLMARK BLUE CROSS