=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114538295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTTS PSYCHOLOGICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2020
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9205 W RUSSELL RD STE 240
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-793-4358
-----------------------------------------------------
Fax | 702-793-4301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 HONORS COURSE DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-508-2153
-----------------------------------------------------
Fax | 702-793-4301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRIAN POTTS
-----------------------------------------------------
Credential | PSY-D
-----------------------------------------------------
Telephone | 702-508-2153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------