Healthcare Provider Details

I. General information

NPI: 1639534480
Provider Name (Legal Business Name): MICHAEL HENRY POTTER MLADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 WEST ST 2ND FLOOR
KEENE NH
03431-3361
US

IV. Provider business mailing address

1251 US ROUTE 10
LEMPSTER NH
03605-3302
US

V. Phone/Fax

Practice location:
  • Phone: 603-355-0157
  • Fax: 603-355-0159
Mailing address:
  • Phone: 603-863-7948
  • Fax: 603-355-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0179
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: