Basic Information
| Provider Information | |||||||||
| NPI: | 1609985332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MAC, MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2130 SW 5TH AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972014976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039637756 | ||||||||
| FaxNumber: | 5039637711 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 SW 5TH AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972014976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039637756 | ||||||||
| FaxNumber: | 5039637711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 86-01-03 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.