Healthcare Provider Details

I. General information

NPI: 1457562290
Provider Name (Legal Business Name): MR. KEITH LESLIE POTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 E BASELINE RD SUITE B2
GILBERT AZ
85234-2726
US

IV. Provider business mailing address

2277 E PALM BEACH DR
CHANDLER AZ
85249-4663
US

V. Phone/Fax

Practice location:
  • Phone: 480-539-5629
  • Fax: 480-539-5669
Mailing address:
  • Phone: 480-220-5547
  • Fax: 480-539-5669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: