Healthcare Provider Details

I. General information

NPI: 1841924297
Provider Name (Legal Business Name): FALLON RAE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 N MUSTANG RD
MUSTANG OK
73064-7214
US

IV. Provider business mailing address

185 ROUTE 70
TOMS RIVER NJ
08755-0906
US

V. Phone/Fax

Practice location:
  • Phone: 716-796-3416
  • Fax:
Mailing address:
  • Phone: 732-806-0091
  • Fax: 732-813-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-87676
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: