Healthcare Provider Details

I. General information

NPI: 1902808736
Provider Name (Legal Business Name): DAVE POTTER L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 S WASHINGTON ST
MOSCOW ID
83843-3049
US

IV. Provider business mailing address

1009 TOLO TRL
MOSCOW ID
83843-8767
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-0619
  • Fax:
Mailing address:
  • Phone: 208-882-6834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-3724
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: