Healthcare Provider Details

I. General information

NPI: 1114586195
Provider Name (Legal Business Name): EVIANNE CHANEL POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 9TH AVE NE STE 300
SEATTLE WA
98105-4762
US

IV. Provider business mailing address

1221 MINOR AVE APT 104
SEATTLE WA
98101-2809
US

V. Phone/Fax

Practice location:
  • Phone: 206-234-6932
  • Fax:
Mailing address:
  • Phone: 530-410-9740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: