Provider Demographics
NPI:1174718563
Name:POTLER, RANDI MICHELLE (MPT)
Entity type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:MICHELLE
Last Name:POTLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1205 YORK RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-296-9195
Mailing Address - Fax:410-296-9197
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 19
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-296-9195
Practice Address - Fax:410-296-9197
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD532P058HMedicare PIN