Healthcare Provider Details

I. General information

NPI: 1386943280
Provider Name (Legal Business Name): EARL ROSS POTEET LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 FAIRWAY VLG
PUEBLO WEST CO
81007-3621
US

IV. Provider business mailing address

117 FAIRWAY VLG
PUEBLO WEST CO
81007-3621
US

V. Phone/Fax

Practice location:
  • Phone: 303-908-8623
  • Fax:
Mailing address:
  • Phone: 303-908-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW-1809
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: