Healthcare Provider Details

I. General information

NPI: 1174636500
Provider Name (Legal Business Name): DR. BRENT C POTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W COLLEGE AVE
SPOKANE WA
99201-2010
US

IV. Provider business mailing address

PO BOX 528
BETHEL AK
99559-0528
US

V. Phone/Fax

Practice location:
  • Phone: 509-324-1420
  • Fax:
Mailing address:
  • Phone: 970-543-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00007704
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2012832
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLH0007704
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLH00007704
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60721362
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: