Healthcare Provider Details

I. General information

NPI: 1790404150
Provider Name (Legal Business Name): MELINDA PEARL POTTER MS, PLMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELINDA PEARL SHANNON

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 09/22/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E 10TH ST
OGALLALA NE
69153-1442
US

IV. Provider business mailing address

PO BOX 161
PAXTON NE
69155-0161
US

V. Phone/Fax

Practice location:
  • Phone: 308-284-6519
  • Fax:
Mailing address:
  • Phone: 435-503-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13258
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3820
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: