Healthcare Provider Details

I. General information

NPI: 1174775811
Provider Name (Legal Business Name): BRIAN S. POTTER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE SUITE 700
MEMPHIS TN
38104-6638
US

IV. Provider business mailing address

1211 UNION AVE SUITE 700
MEMPHIS TN
38104-6638
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5182
  • Fax: 901-287-6700
Mailing address:
  • Phone: 901-287-5182
  • Fax: 901-287-6700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3108
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: