MEDICARE: TARA B POTTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205527173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA B POTTER

Provider Business Mailing Address
First Line	:	PO BOX 259
Second Line	:
City	:	SHALIMAR
State	:	FL
Zip	:	32579-0259
Country	:	US
Telephone Number	:	850-362-6824
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 W NINE MILE RD
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32534-1954
Country	:	US
Telephone Number	:	850-362-6824
Fax Number	:	850-607-6932

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/14/2026

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Directions to “ TARA B POTTER ” Practice Location

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