Healthcare Provider Details

I. General information

NPI: 1104493014
Provider Name (Legal Business Name): MELISSA POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 E GENEVA DR
DEWITT MI
48820-9569
US

IV. Provider business mailing address

1016 E GENEVA DR
DEWITT MI
48820-9569
US

V. Phone/Fax

Practice location:
  • Phone: 517-819-8928
  • Fax:
Mailing address:
  • Phone: 517-819-8928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014498
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: